
Class RHjJl/ 

Book Wa 

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COPYRIGHT DEPOSIT. 



A TREATISE 



ORTHOPEDIC SURGERY 



BY 

EOYAL WHITMAN, M.D. 

CLINICAL LECTURER AND INSTRUCTOR IN ORTHOPEDIC SURGERY IN THE COLLEGE OP PHYSICIANS 

AND SURGEONS OP COLUMBIA UNIVERSITY, NEW YORK; ASSOCIATE SURGEON TO THE 

HOSPITAL FOR RUPTURED AND CRIPPLED", ORTHOPEDIC SURGEON TO THE 

HOSPITAL OP ST. JOHN'S GUILD. 

MEMBER OF THE ROYAL COLLEGE OP SURGEONS OF ENGLAND; MEMBER AND SOMETIME PRESIDENT 

OP THE AMERICAN ORTHOPEDIC ASSOCIATION; CORRESPONDING MEMBER OF THE 

BRITISH ORTHOPEDIC SOCIETY; MEMBER OF THE NEW YORK SURGICAL 

SOCIETY, ETC. 



THIRD EDITION, REVISED AND ENLARGED 



ILLUSTRATED WITH FIVE HUNDRED AND FIFTY-FOUR ENGRAVINGS 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YORK 

1907 



*$ 



LIBRARY of OONGRESS 

Two Copies Received 
JAN 101907 
Copyrieht Entw M 

. A XXc.No. 

COPY B. 



Entered according to the Act of Congress, in the year 1907, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTER. 



TO 

VIRGIL P, GIBNEY, M.D., LL.D. 

THIS VOLUME IS INSCRIBED 

AS A. TOKEN OF FRIENDSHIP ASSURED BY LONG ASSOCIATION 

AND OF APPRECIATION OF HIS EFFORTS 

FOR THE ADVANCEMENT OF 

ORTHOPEDIC SURGERY 



PREFACE TO THE THIRD EDITION 



This volume presents a thorough revision and amendment 
of the last edition. New material and many illustrations have 
been added, and the author trusts that it fairly represents this 
department of medicine at the date of issue. 



283 Lexington Avenue, New York, 
December, 1906. 



FROM THE PREFACE TO THE FIRST EDITION. 



In the preparation of this volume it has been the purpose of 
the author to present as adequately as might be the practice of 
Orthopedic Surgery of the present day. 

The student of this subject is especially concerned with the 
mechanics of the human machine with its development, with its 
capacity at different periods of life and under varying conditions, 
and with those affections that lead to deformity or that otherwise 
impair its usefulness. He is concerned, moreover, not only with 
the local and immediate effects of disease or disability, but with 
its general influence upon the entire mechanism, and with its 
ultimate consequences as well. 

Orthopedic Surgery occupies a broad field and one of very 
great and general interest. Its most distinctive advance in recent 
years has been toward the prevention of deformity, an advance 
that has been made possible by the better understanding of its 
predisposing and exciting causes. As a natural consequence, 
treatment has become more direct, more simple, and more effec- 
tive. It has been the purpose of the author to emphasize this 



vi PREFACE 

aspect of the subject, which is of the greatest importance to the 
general practitioner, who so often has the opportunity to recognize 
disease or disability in its incipiency, when its progress may be 
checked by timely treatment. 

He has endeavored to present Orthopedic Surgery as far as 
possible objectively, and in a manner that has proved acceptable 
to students and practitioners in clinical teaching. Thus the 
selection of each subject and the space that has been allotted to 
it has been determined primarily by its relative importance in 
the actual work of orthopedic clinics. He has been at some 
pains, also, to outline methods of examination, to explain the 
phenomena of the symptoms and so to describe and to illustrate 
the causes and effects of disease and disability as to indicate, in 
natural sequence, the principles of treatment; but the particular 
methods of the application of these principles, which have been 
described in detail, are always those that have been tested by 
personal experience. 

Although this book is designed particularly for students and 
practitioners of medicine, the author has included statistical and 
other data which he hopes may prove of interest to his fellow- 
workers in this special field. 

The author desires to express his obligation to the gentlemen 
who have assisted him in the collection of statistics, and other- 
wise, whose names are mentioned in the text; to Dr. L. W. Ely 
and to Mr. W. P. Agnew for timely photographs, and especially 
to the Trustees of the Hospital for Ruptured and Crippled, for 
the facilities that have been afforded him in the preparation of 
this work. 



CONTENTS. 



CHAPTER I. 

TUBERCULOUS DISEASE OF THE SPINE. 

PAGE 

Description — Pathology — Etiology — Statistics — General prognosis — 
Symptoms — Physical examination — Contour and flexibility of the 
spine — Divisions of the spine — Landmarks — The differential diagno- 
sis of disease in the lower, middle, and upper regions of the spine — 
Treatment by horizontal fixation and overextension — by braces — 
by plaster jackets — by other means. The selection and adaptation 
of treatment for disease of the different regions of the spine. The 
complications of tuberculous disease of the spine — Abscess — course 
— symptoms — treatment. Paralysis — course — symptoms — treat- 
ment. Forcible correction of deformity — (Calot's operation) — 
Recurrence of Disease — Secondary deformities — Recapitulation. 17 

CHAPTER II. 

NON-TUBERCULOUS AFFECTIONS OP THE SPINE. 

Syphilis — Malignant disease — Osteomyelitis, acute and chronic — Actino- 
mycosis — Injur}' — Traumatic spondylitis — Rhachitic spine — Ty- 
phoid spine — Gonorrhceal arthritis of the spine — Arthritis — Spon- 
dylitis deformans, varieties — Osteitis deformans — Spondylolisthesis 
— Relaxation of pelvic joints — Pain in the back — Neurotic spine — 
Hysterical spine — Sciatic scoliosis — Disease and injury at the sacro- 
iliac articulation 126 

CHAPTER III. 

LATERAL CURVATURE OF THE SPINE. 

Description — habitual and fixed deformity, rotation and lateral devia- 
tion . Pathology — Etiology — Statistics — Varieties — Distribution 
and effects of deformity — Symptoms — Diagnosis — Prognosis— Pre- 
vention of deformity — Desks, chairs — Principles of treatment — 
Treatment — by exercises — general exercises — heavy exercises — 
special exercises — Supports. Forcible correction of deformity — 
Adjuncts in treatment — Duration of treatment 149 

CHAPTER D7. 

DEFORMITIES OF THE SPINE (CONTINUED). DEFORMITIES OF THE CHEST 
FUNCTIONAL PATHOGENESIS OF DEFORMITY. 

Variation in contour of the spine — The round and the flat back — Kyphosis 
' — Lordosis — Treatment — Congenital elevation of the scapula. — 



viii CONTENTS 

PAGE 

Absence of vertebrae — Flat chest — Pigeon chest — Funnel chest — 
Minor deformities — Cervical Ribs — Scapular Crepitus — Absence of 
ribs — -Defective formation of the pectoral muscles — -Absence or de- 
fect of the clavicle — Acquired luxation or subluxation of the clavicle 
— Asymmetrical development — Tables of height, weight, and cir- 
cumference of the chest — -Functional pathogenesis of deformity — 
(Wolff's law) — Atrophy of bone — Hypertrophy of bone .... 223 

CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES AND JOINTS. 

Predisposition — Mode of infection — Latent tuberculosis — Local predis- 
position — Statistics — distribution of disease — location — side affected 
— sex — age. Pathology — -Varieties of disease — synovial — arbores- 
cent, synovial form — lipoma arborescens — rice bodies — caries sicca — 
Septic infection— Progress and method of repair — Prognosis — 
Treatment — operative and mechanical — by drugs — local applica- 
tions — Iodoform filling — X-ray — Active and passive congestion — 
venous stasis (Bier's treatment) 246 

CHAPTER VI. 

NON-TUBERCULOUS DISEASES OF THE JOINTS. 

Syphilitic disease of joints — Gonorrhoeal arthritis — Other forms of 
infectious arthritis — Acute epiphysitis — acute osteomyelitis — Sub- 
acute osteomyelitis — Osteoarthritis and rheumatoid arthritis — 
Varieties — ■ Treatment — Still's disease — Gout — Rheumatism — 
Haemophilia — Haemarthrosis — Scorbutus — Charcot's disease — Other 
forms of arthropathy — -Anchylosis — Treatment 266 

CHAPTER VII. 

TUBERCULOUS DISEASE OF THE HIP-JOINT. 

Pathology — Statistics — Symptoms — Physical signs, distortion, apparent 
lengthening, apparent shortening. Causes of distortion — -Atrophy — 
Causes of actual shortening — Measurements — Lovett's table — 
Kingsley's table — Explanation of physical signs — Differential diag- 
nosis — Principles of treatment — The traction hip brace — The 
Thomas brace — The plaster bandage — Various methods of reducing 
deformity — Comparison of methods of treatment — The long hip 
splint — The hip splint and the plaster spica — Other forms of appa- 
ratus — Bilateral hip disease — Hip disease in infancy — Hip disease 
in adult life — Abscess — statistics — treatment — Operative treat- 
ment — exploration — excision — reduction of resistant deformity — 
Prognosis, mortality, functional results — Secondary deformities 
of hip disease—Treatment — -Final results 298 

CHAPTER VIII. 

NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT. 

Statistics — Traumatisms at the hip — Acute infectious arthritis — Sub- 
acute arthritis — Spontaneous dislocation — Gonorrhoeal arthritis— 



CONTENTS ix 

PAGE 

Extra-articular disease — Bursitis — Malignant disease at the hip-joint 

— Cysts of the femur — Arthritis deformans 398 

CHAPTER IX. 

TUBERCULOUS DISEASE OF THE KNEE-JOINT. 

Pathology — Etiology — Statistics — Symptoms, primary and secondary 
distortions — Shortening and lengthening — Diagnosis — Differential 
diagnosis — Treatment — Reduction of deformity — Forms of braces 
— Accessories in treatment — Extra-articular disease — Abscess — 
Operative treatment — arthrectomy — excision, amputation — Prog 

■\. nosis — mortality — functional results — General conclusions . . . 406 

CHAPTER X. 

NON-TUBERCULOUS AFFECTIONS OF THE KNEE-JOINT. 

Injury in childhood — Acute Synovitis — Chronic Synovitis — Internal 
derangement of the knee-joint — Prepatellar bursitis — Pretibial 
bursitis — Injury of tibial tubercle — Bursse and cysts in the pop- 
liteal region — Hyperplasia — Quiet effusion — Acquired genu recur- 
vation — Congenital genu recurvatum — rudimentary or absent 
patella — Congenital displacement of patella — Slipping pateUa — 
Elongation of the ligamentum patella? — Snapping knee — Congenital 
contraction at the knee — General contractions 434 

CHAPTER XL 

DISEASES AND INJURIES OF THE ANKLE-JOINT. 

Tuberculous disease — Pathology — Etiology — Statistics — Symptoms — 
Diagnosis — Treatment — Prognosis — Tuberculous disease of the 
tarsus — Statistics — Treatment — Sprain of the ankle — Chronic sprain 
— Swelling about the ankles — Tenosynovitis — Other affections of 
the ankle-joint 450 

CHAPTER XII 

DISEASES AND INJURIES OF THE ARTICULATION OF THE 
UPPER EXTREMITY. 

Tuberculous disease of the shoulder-joint — Pathology — Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous disease of the 
elbow-joint — Pathology — Statistics — Symptoms — Treatment — 
Prognosis — Tuberculous disease of the wrist-joint — Symptoms — 
Treatment — Prognosis — Spina ventosa — Periarthritis at the 
shoulder-joint — Chronic bursitis at the shoulder — Sprain of the 
wrist — Acute and chronic tenosynovitis at the wrist 466 

CHAPTER XIII. 

DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital dislocation of the shoulder — Obstetrical paralysis and dis- 
location — Treatment — Operation on Brachial plexus — Recurrent 



x CONTENTS 

PAGE 

dislocation of the shoulder — Congenital deformities of the elbow — 
Cubitus valgus — Cubitus varus — Subluxation of the wrist — Con- 
genital deformities at the wrist — Club-hand— Varieties — Treat- 
ment — Club-hand associated with defective development — Con- 
genital contraction of the fingers — Webbed fingers — Congenital dis- 
placement of phalanges — Trigger finger— Mallet finger — Base-ball 
finger — Dupuytren's contraction 482 

CHAPTER XIV. 

CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO GENERAL 
DISTORTIONS. 

Rhachitis — Etiology — Pathology — Symptoms, deformities — Prognosis- 
Treatment — " Late rickets" — Chondrodystrophia — Infantile scor- 
butus — Fragilitas ossium — Osteomalacia — Osteitis deformans — 
Secondary hypertrophic osteo-arthropathy — Acromegalia . . . 498 

CHAPTER XV. 

CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. 

Congenital dislocation of the hip-joint — Statistics — Pathology — Etiology 
— Symptoms, unilateral, bilateral — Anterior — Supracotyloid — Diag- 
nosis — Differential diagnosis — Treatment — the Lorenz operation — ■ 
Details and modifications— Prognosis — Treatment of older subjects 
— Treatment in infancy — Palliative treatment — The open operation 
Arthrotomy— the intermediate operation — secondary osteotomy — 
The Hoffa-Lorenz operation — Review of treatment — Variations 
in treatment — Congenital subluxation of the hip — Snapping hip 
— Coxa vara— Pathology — Etiology — Statistics — Symptoms, uni- 
lateral, bilateral— Diagnosis — Treatment — mechanical — operative 
— Forcible abduction — Osteotomy — Cuneiform — Linear — Fracture 
of the neck of the femur — Traumatic separation of the epiphysis 
of the head of the femur — Partial epiphyseal separation — Fracture 
in adult fife — The author's treatment for complete — for impacted — 
Coxa valga 513 

CHAPTER XVI. 

DEFORMITIES OF THE BONES OF THE LOWER EXTREMITY. 

Bow-leg — Knock-knee — Statistics — Etiology — The outgrowth of defor- 
mity — Genu valgum — Description — Attitudes — Secondary deform- 
ities — Gait — Unilateral deformity — Pathology — Treatment — expec- 
tant — mechanical — operative— Genu varum, varieties — Symptoms 
— Treatment — expectant — mechanical — operative— Anterior bow- 
leg — General rheachitic distortions 569 

CHAPTER XVII. 

DISEASES OF THE NERVOUS SYSTEM. 

Acute anterior poliomyelitis — Pathology — Etiology— Statistics — Symp- 
toms—Diagnosis — Prognosis — Causes of Deformity — Deformity in 



CONTENTS 



various regions — Subluxation — Retardation of growth — Principles 
of Treatment — Treatment, mechanical, operative — Tendon and mus- 
cle transplantation — Arthrodesis— Nerve grafting — Recapitulation . 598 

CHAPTER XVIII. 

DISEASES OF THE NERVOUS SYSTEM (CONTINUED). 

Cerebral paralysis of childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital paralysis — Acquired paralysis 
— Hemiplegia — Paraplegia — Treatment, mechanical, operative — 
— Prognosis — Spastic spinal paraplegia — Progressive muscular 
atrophy — Varieties — Symptoms — Hereditary ataxia — Neuritis — 
Hysterical and functional affections of the joints — "Hysterical" 
hip — Differential diagnosis — " Hysterical" deformities — " Hysteri- 
cal" club-foot — "Hysterical" scoliosis — Neurotic joints .... 623 

CHAPTER XIX. 

CONGENITAL AND ACQUIRED TORTICOLLIS. 

Description — Statistics — Congenital torticollis — Etiology — Hsematoma 
of the sternomastoid muscle — Acquired torticollis — Varieties — 
Acute torticollis — -Etiology — Symptoms — Diagnosis — Treatment of 
chronic torticollis — mechanical, operative — Treatment of acute 
torticollis — Spasmodic torticollis — Etiology — Pathology — Treat- 
ment — Exceptional forms of torticollis — paralytic — diphtheritic — 
cervical opisthotonos, rhachitic — ocular — psychical 642 

j CHAPTER XX. 

DISABILITIES AND DEFORMITIES OF THE FOOT. 

General description of the foot and of its functions, the arches, the foot 
as a passive support, in activity — Improper postures — Movements 
— Function of the muscles — Strength of the muscles — The foot as a 
mechanism — The weak foot or so-called flat-foot — Description — 
Anatomy — Pathology — Etiology — Statistics — Symptoms — Diagno- 
sis — Varieties — Weak foot in childhood — Exceptional forms — Treat- 
ment — Preventive — Exercises — Support — Construction of brace — 
The rigid weak foot — Forcible correction of deformity — Subsequent 
treatment — Adjuncts in treatment — Operative treatment . . . 665 

CHAPTER XXI. 

DISABILITIES AND DEFORMITIES OF THE FOOT (CONTINUED). 

The hollow foot — Varieties and treatment — Anterior metatarsalgia — 
Morton' s neuralgia — Etiology — Treatment — Achillobursitis — Strain 
of the tendo Achilles — Calcaneobursitis — Plantar neuralgia — Ery- 
thromelalgia — Intermittent limp — Hallux rigidus — Painful great 
toe — Hallux varus — Pigeon toe — Metatarsus varus — Hallux valgus 
— Hammer toe — Overlapping toes — Fracture of metatarsus — Exos- 
toses — Displacement of the peronei tendons — Shoes, effects of 
improper shoes — Demonstration of the proper shoe— Socks . . . 716 



xii CONTENTS 

CHAPTER XXII. 

DEFORMITIES OF THE FOOT. 

PAGE 

Talipes — Description — Varieties — Statistics of talipes, congenital and 
acquired — Relative frequency of the different varieties — Congenital 
talipes — Etiology — Anatomy — Symptoms — Principles of treatment 
of infantile club-foot — Treatment — mechanical — by plaster band- 
age — by braces — restoration of function — supervision — Treatment 
in older subjects — forcible manual correction — tenotomy — Wolff's 
treatment, reduction of deformity by wrenches — Phelps' operation 
— Operations on the bones — Astragalectomy — Osteotomy — Me- 
chanical treatment — Other varieties of congenital talipes — varus 
— equinus — calcaneus — valgus — equinovalgus — calcaneo valgus — 
calcaneovarus — equinocavus — valgocavus — Congenital talipes as- 
sociated with defective development — with absence of fibula — with 
absence of tibia — with defective formation of the foot — Constricting 
bands — Congenital amputation — Congenital oedema — Spina bifida 
and talipes 752 

CHAPTER XXIII. 

DEFORMITIES OF THE FOOT (CONTINUED). 

Acquired talipes — Etiology — Diagnosis — Talipes equinus — Description — ■ 
— Etiology — Symptoms — Treatment — mechanical — operative — 
Talipes calcaneus — Description, development of deformity — Symp- 
toms — Treatment — mechanical, operative — Willet's operation — The 
author's operation — Talipes calcaneovarus and calcaneo valgus — 
Talipes equinovarus and talipes equinovalgus — Talipes valgus — 
Traumatic valgus — Other varieties of acquired talipes — Tendon 
transplantation in the treatment of paralytic talipes — Tendon 
transplantation and arthrodesis — Tendon splicing — Arthrodesis 
and other procedures 813 



ORTHOPEDIC SURGERY. 



CHAPTER I. 

TUBERCULOUS DISEASE OF THE SPINE. 

Synonym. — Pott's disease. 

Pott's disease is a chronic destructive process of the bodies 
of the vertebrae. The spine bends at the weakened point, and 
the upper part, sinking downward and forward, throws into 
relief one or more of the spinous processes at the seat of the dis- 
ease; thus an angular posterior projection is formed. It is 
called Pott's disease because such deformity, accompanied by 
pain and sometimes by paralysis, was first described accurately 
by Percival Pott, in 1779. Angular deformity is, however, simply 
the evidence of destruction of a portion of the anterior part of 
the vertebral column. Thus it might be the result of fracture, 
or of the erosion of an aneurism, or of malignant disease, or 
syphilis, or other pathological process; but deformity from such 
causes is not now included under Pott's disease, nor is the term 
now synonymous with deformity. In the modern sense it sig- 
nifies tuberculous disease of the bodies of the vertebrae, of 
which the early symptoms may be detected and of which the 
deforming effects may be checked and even prevented by proper 
treatment. 

The compression and collapse of the affected parts cause the 
characteristic angular projection at the seat of the disease 
(Fig. 2). If one vertebral body is destroyed the projection will 
be sharp; if several are implicated it will be less angular, and 
if one side of a body breaks down before the other there may 
be a lateral as well as a posterior distortion. 

The size of the deformity and its effect upon the individual 
depend in great degree upon its situation. If the disease is 
at either extremity of the spine the angular projection is slight 
because the area of the spine directly involved in the deformity 



18 



OR THOPEDIC SURGERY 



is small compared to that which is free from disease (Fig. 5). 
But if the centre of the spine is affected the opportunity for 
deformity is great, because the entire column may enter into 
the formation of the angular kyphosis. In such cases the internal 
organs are compressed and the effect upon the vital mechanism 
is disastrous (Fig. 23). 

Pott's disease, as contrasted with tuberculosis of other bones 
and joints, is peculiar in its inaccessibility; in its proximity to 
important parts, the vital organs in front 
and the spinal cord behind. Finally, in 
that the effects of disease and deformity 
influence in much greater degree the entire 
mechanism of the body. 

Pathology. — The minute changes that 
characterize tuberculosis of bone in gen- 
eral are described in Chapter V. 

The first indication of the disease is 
usually found in the anterior part of a 
vertebral body just beneath the fibroperi- 
osteal layer of the anterior longitudinal 
ligament. From this point the granulation 
tissue advances along the front of the spine, 
and following the course of the bloodvessels 
it invades the adjacent vertebral bodies. 
In other instances the process may begin 
in the interior of a vertebral body, most 
often in several minute foci near the upper 
or lower epiphysis. These coalescing, gradu- 
ally enlarge, forming a cavity, surrounded 
for a time by unbroken cortical substance, 
of"^^d£ which finally collapses under the pressure 
lumbar vertebrae— with the of the superincumbent weight. Occasion- 
nard.) nS "^ y ~ a ^y * ne disease advances beneath the 
anterior ligament without implicating deeply 
the substance of the bone — a form of tuberculous periostitis, 
"spondylitis superficialis." 

The intervertebral disks appear to offer some resistance to 
the extension of the disease from one vertebra to another, but 
when the bone is destroyed on either side they quickly disin- 
tegrate and disappear. The posterior part of the spinal column 
usually remains free from disease, with the exception of the 
pedicles and articulations that may be in direct contact with it. 




TUBERCULOUS DISEASE OF THE SPINE 19 

In rare instances the process may begin in a lamina or spinous 
process, or in one of the small joints; but such forms of local 
tuberculosis could hardly be classed as Pott's disease. 

The course and outcome of the disease depend upon its type. 
In one instance the area of primary infection is small and the 




Pott's disease. 

localj-esistance is sufficient to check its further progress, so that 
cure without deformity may follow. In another the disease 
is inactive and the granulation tissue undergoes a fibroid trans- 
formation or becomes ossified. In such cases deformity may 
appear and slowly increase, practically without symptoms. 
In most instances, however, the infected granulations advance 



20 ORTHOPEDIC SURGERY 

more rapidly, destroying the bone or other tissue with which 
they come in contact. There is the usual retrograde metamor- 
phosis to cheesy degeneration, and very frequently liquefaction 
and abscess formation follow. 

As a rule, in those cases of moderate severity that come to 
autopsy during the progressive stage of the disease, one finds, 
on dividing the thickened tissues in front of the spine, a cavity 
the walls of which are lined with granulation tissue in various 
stages of degeneration, and containing puriform fluid. The 
adjoining vertebral bodies present a worm-eaten appearance, 
and one or more of them is partially destroyed. Small frag- 
ments of necrosed bone, "bone sand," may be recognized, and 
occasionally sequestra of considerable size are present. 

If the disease begins in the interior of a vertebral body it may 
extend backward as well as forward, and forcing its way into 
the vertebral canal it may press upon the spinal cord, and 
even before deformity is apparent involve its coverings, thus 
causing paralysis of the parts below. Less often pressure on the 
cord may be due to the presence of an abscess or to a projecting 
fragment of bone. The calibre of the spinal canal may be con- 
stricted somewhat by the pressure of the superincumbent weight 
upon the softened and thickened tissues at the seat of disease; but, 
as a rule, its capacity is not directly lessened by the angular dis- 
tortion, nor does the degree of deformity directly influence the 
frequency of paralysis. 

Although the disease may begin in multiple primary foci of 
infection over an extended area, or in two or more distinct re- 
gions of the spine simultaneously, yet clinical observation seems 
to show that it is, in most instances, originally confined to one 
or two adjacent bodies. From this central point it may extend 
in either direction until half the spine is implicated; but in ordi- 
nary cases the final area of deformity and rigidity shows that 
from three to six bodies are more or less involved before cure is 
established. 

If the disease is limited in extent, the eroded surfaces of the 
adjoining vertebrae may come into direct contact; but if several 
vertebral bodies have been destroyed, the upper portion of the 
spine as it sinks downward is often displaced backward, so that 
the anterior aspect of one or more of the upper segments may 
be apposed to the superior surface of the first body of the lower 
section (Fig. 3). Less often there may be forward displace- 
ment of the upper part upon the lower (Fig. 1). 



TUBERCULOUS DISEASE OF THE SPINE 



21 



At all stages of the disease resistance to its progress and efforts 
at repair are evident in the affected parts. When this resist- 
ance overbalances the tendency to degeneration its progress is 
checked. 



as 




% 



Destruction of the bodies of the third, 
fourth, fifth, sixth, and seventh dorsal ver- 
tebrae; partial destruction of three others. 
(Menard.) 



The deformity corrected, showing the 
area of the destructive process. (Menard.) 



Repair is accomplished occasionally by contact and solid 
union of the adjoining surfaces of softened bone; but usually 
the anchylosis is in part fibrous, in part cartilaginous, and in 
part bony, and this union may be further strengthened by a 
callous formation from the thickened tissues about the seat of 
the disease. In many instances the articular processes, the 



22 ORTHOPEDIC S UR GER Y 

pedicles, and laminse become anchylosed before repair has ad- 
vanced appreciably in the anterior portion of the column. 

Cure may be absolute, as when no vestige of the disease 
remains; it may be practically assured, as when the diseased 
products undergo calcareous degeneration and are shut in by 
a layer of solid bone. In other instances the disease becomes 
quiescent or but slowly advances, showing its presence by ex- 
acerbations of pain or by the formation of an abscess long after 
active symptoms have ceased. 

Etiology.— The etiology of tuberculosis of the spine does not 
differ from that of tuberculosis of other bones; the subject is 
considered in Chapter V. 

Relative Frequency. — Tuberculosis of the spinal column is 
more common than of any other single bone or joint, as might 
be expected from its greater area. This is illustrated by the 
statistics of tuberculous disease treated in the out-patient depart- 
ment of the Hospital for Ruptured and Crippled during a period 
of twenty years, 1885-1904. 

Tuberculosis of the spine ....... 4299 cases. 

of the hip 3329 " 

" of other joints inclusive .... 3222 " 



Also by statistics of the Boston Children's Hospital for a similar 
period, 1869-1888: 

Tuberculosis of the spine ....... 1864 cases. 

" of the hip, knee, ankle, shoulder, elbow, and 

wrist combined ...... 1856 " 



Age. — Pott's disease, although far more frequent in the middle 
period of childhood, from the third to the tenth year, may occur 
at any time from earliest infancy to extreme old age. 

In a series of 1259 consecutive cases of tuberculosis of the 
spine collected from the records of the out-door department 
of the Hospital for Ruptured and Crippled, analyzed by Drs. R. 
T. Frank and C. Gunter, the ages of the patients at the supposed 
time of onset of the disease appeared to be as follows: 

Less than 1 year 38 = 3 . 1 per cent 

Between 1 and 2 years 176 = 14.2 " 

3 " 5 " 627 = 50.2 " 

6 " 10 " 234 = 18.3 " 

11 " 20 " 89 = 7.2 " 

21 " 30 - 43 = 3.5 " 

31 " 50 " 31 = 2.6 " 

Over 50 " 11 = 0.8 " 



TUBERCULOUS DISEASE OF THE SPINE 



23 



The youngest patient was two months old, the oldest seventy- 
one years. 

Thorndike, 1 of Boston, from the records of the Boston Chil- 
dren's Hospital for thirteen years, 1883 to 1896, collected 115 
cases of tuberculosis of the spine in children of two years or less. 
Seven of these were less than six months, and twenty were under 
one year in age. 

Howard Marsh 2 has called attention to Pott's disease of the 
aged, and cites three cases in subjects of sixty or more years 
of age. 

Sex. — Sex exercises comparatively little influence on the lia- 
bility to disease of this region. Of 3797 cases collected by Mohr, 
Gibney, Fischer, Taylor, and Bradford and Lovett, quoted 
by Hoffa, 2045 were in males and 1752 were in females. Of 
1367 cases collected by Frank and Gunter, 708 (52 per cent.) 
were in males and 659 (48 per cent.) were in females; and in 
2455 cases tabulated by Knight, 1329 were in males and 1126 
in females. Of these combined cases from the Hospital for 
Ruptured and Crippled, 3822 in number, 53.2 per cent, were 
in males and 46.8 per cent, in females. 

The Situation of the Disease.— The dorsolumbar section of 
the spine is most often affected. Cervical disease is compara- 
tively infrequent. 

In the series of 1355 cases from the records of the Hospital 
for Ruptured and Crippled, the attempt was made to locate 
the origin of the disease by the most prominent spinous process 
in the tracing. The following are the conclusions: 



First . 

Second 

Third . 

Fourth 

Fifth . 

Sixth . 

Seventh 

Eighth 

Ninth 

Tenth 

Eleventh 

Twelfth 



•vical. 


Dorsal. 


Lumbar. 


Lumbosa 


3 


26 


94 


13 


3 


43 


96 


.. 


15 


42 


64 




20 


46 


57 




13 


49 


6 




22 


76 






24 


82 
97 
92 
110 
71 








120 


.. 


.. 



No deformity, cervical ......... 2 

dorsal 31 

lumbar 22 



Disease in two regions of the spine 



Transactions American Orthopedic Association, 1896, vol. ix. 2 Ibid., 1891, vol. iv, 



24 



ORTHOPEDIC SURGERY 



Similar statistics are recorded by Julius Dollinger, 1 of Budapest, 
of 700 cases of Pott's disease. Of these the situation of the pri- 
mary disease could be ascertained in 538. In 63 the disease 
was of the cervical, in 321 of the dorsal, and in 154 of the 
lumbar region. 

The relative frequency of disease of the different dorsal and 



lumbar vertebrae was as fol 



First . 

Second 

Third . 

Fourth 

Fifth . 

Sixth . 

Seventh 

Eighth 

Ninth 

Tenth 

Eleventh 

Twelfth 



Dorsal. 
6 
7 
12 
10 
19 
17 
33 
36 
36 
43 
38 
64 



Lumbar. 
59 



The proportionate length of the different sections of the spine 
at the age of five years is, according to Disse: 2 



20.2 
45.6 
34.2 



If this be contrasted with the percentage of the cases of disease 
of each section, it will show that the frequency of the disease 
in the different regions of the spine does not correspond to the 
area, as has been suggested, but that it is proportionately much 
less frequent in the cervical and much more frequent in the dor- 
sal region. 

Bollinger. Fmnk and Gunler. Area. 

11.7 percent. Cervical . . 7.7 percent. — 20.2 



Cervical 

Dorsal 

Lumbar 



59.6 
28.6 



Dorsal 

Lumbar 



66.4 
25.6 



This may be explained apparently by the greater strain to 
which the middle and lower parts of the spine are subjected, as 
well as by the relative proportion of cancellous tissue which offers 
the opportunity for infection. 

It may be noted in this connection that the proportionate 
length of the sections of the spine changes somewhat with the 
age, as is illustrated by the following table, the scale being 1000 : 3 



1 Die Behandlung der Tuberculosen Wirbelentzundung, Stuttgart, 1898. 

- Skeletlehre, 1896. 

3 Moser, in Yoachimsthal's Handb. der Orth. Chir., 1905, p. 521. 



TUBERCULOUS DISEASE OF THE SPINE 25 

Cervical. Thoracic. Lumbar. 

At birth 240 490 260 

Three years 214 479 306 

Five years 206 486 308 

Eleven years 209 500 290 

Fourteen years 216 500 284 

Adult 195 482 323 

Prognosis. — The prognosis in tuberculous disease is discussed 
in Chapter V. Pott's disease is the most dangerous of all the 
tuberculous affections of the bones or joints, as would be ex- 
pected from the relative importance of the structure affected 
and of the parts lying in contact with it. 

It is evident also that the degree of deformity and its situa- 
tion have a direct influence on the prognosis. In disease of 
either extremity of the spine the direct deformity is insignifi- 
cant and the secondary effect upon the trunk is slight. 

In the typical "hump-back" deformity, however, the con- 
tents of the thorax and abdomen are necessarily compressed; 
the bloodvessels are distorted, and the calibre of the aorta, which 
is more directly affected, is often much diminished; respiration 
is made difficult, and the circulation is impeded; as a conse- 
quence, the heart is usually hypertrophied and valvular insuffi- 
ciency is not infrequent. Thus the vital functions, which are 
carried on at a disadvantage even under favorable conditions, 
become impossible under the added strain of unfavorable sur- 
roundings, overwork, or disease. It is a matter of common 
observation that few of those who are markedly deformed reach 
old age. On the other hand, it may be assumed that slight 
deformities, or those which do not as directly interfere with the 
vital functions, exercise but little influence upon the future well- 
being of the patient. 

Although the absolute mortality of Pott's disease cannot be 
accurately estimated, it may be stated that at least 20 per cent, 
of all patients die during the progress of the disease and within 
a few years after its onset, from causes directly or indirectly 
dependent upon the local lesion. Some of these die from gen- 
eral dissemination of the tuberculous infection and tuberculous 
meningitis; some from exhaustion following septic infection 
and long-continued suppuration, or from amyloid degeneration 
of the internal organs; some from tuberculosis of the lungs, and 
many from intercurrent affections that are fatal because of the 
devitalizing influence of the disease and its complications. 

The prognosis of Pott's disease in the individual case is in- 
fluenced by many considerations. In one instance the family 



26 ORTHOPEDIC S URGER T 

history is good, the surroundings are favorable, the patient is 
in good condition, and the disease is in the early stage; one is 
then inclined to look upon it as an accident, and hardly considers 
the possibility of a fatal termination; while in another case the 
weakness and undervitalization of the body are so evident that 
the affection of the spine seems but an incident of a general de- 
generation. 

Symptoms. — The most distinctive sign of Pott's disease is 
deformity. At an early stage of the process there may be but 
a slight irregularity in the contour of the spine, and if several 
adjacent vertebral bodies are affected the projection may be 
somewhat rounded in outline; but as compared with other de- 
formities of the spine, that of Pott's disease is characteristically 
angular, and as its cause is loss of substance, its formation is 
accompanied by and must have been preceded by the symptoms 
of bone disease. 

Deformity is thus the evidence of a destructive process that 
may have existed for weeks or months even, and only by its early 
recognition can the ideal result — the prevention of deformity — 
be attained. The spine which, although weak, is still straight 
may be held straight; but when the deformity is present, it can 
be remedied only in part, and it may be difficult even to check 
its further progress. For as the upper segment of the spine 
sinks forward and downward, the influences of compression and 
attrition increase the activity of the local process and aggravate 
its effects. 

For many years angular deformity was thought to be the es- 
sential sign of Pott's disease, and even now the fact is not gener- 
ally recognized that the detection of tuberculous ostitis of the 
spine in the early stage is both possible and easy, if one will 
apply the same methods that serve for the diagnosis of other 
affections not attended by a symptom so obvious as external 
deformity. It is to such application of the principles of differ- 
ential diagnosis that attention is called. 

The spine is the chief support of the body, possessing a free 
mobility that accommodates it to every movement of the trunk 
and to every motion of the limbs even. It is evident, therefore, 
that the symptoms of a destructive disease must be pain, weak- 
ness, and impairment of normal motion. Motion and support 
are not, however, the only functions of the spine; it contains 
the spinal cord, from which branch the nerves that supply the 
organs and members of the body. This may be implicated at 



TUBERCULOUS DISEASE OF THE SPINE 27 

an early stage of the affection and the sudden onset of paralysis 
may overshadow the symptoms of the original disease. In 
other instances the tumor of an abscess — one of the common 
accompaniments of tuberculous disease of the bone — may in- 
terfere with the functions of important parts lying in the neighbor- 
hood of the spine, and peculiar symptoms, due to this cause, 
may attract attention before the primary disease is suspected. 
Such symptoms may be misleading and it is well, therefore, to 
consider them apart from those that indicate the primary effect 
of the disease upon the spine, considered as an elastic support. 
These direct symptoms usually precede and always accompany 
the secondary or complicating symptoms, and upon them the 
diagnosis depends. 

The primary and diagnostic symptoms of Pott's disease may 
be classified as follows: 

(a) Pain. 

(6) Stiffness. 

(c) Weakness. 

(d) Awkwardness. 

(e) Deformity. 

(a) Pain. — At first thought, one might expect the pain of Pott's 
disease to be localized at the affected vertebrae, and to be accom- 
panied by sensitiveness to pressure or even by infiltration and 
swelling of the neighboring tissues; but it will be remembered 
that the bodies of the vertebrae are in the interior of the trunk 
practically speaking, as near to its anterior as to its posterior 
surface (Fig. 9), and that the products of the disease pass down- 
ward and forward, rarely backward. Thus sensitiveness to 
pressure on the projecting spinous processes is unusual, and 
palpation, except in the cervical region, is of comparatively little 
diagnostic value. 

The pain of Pott's disease is not localized in the back, in the 
neighborhood of the disease, because the filaments that supply 
the bodies of the vertebrae are insignificant parts of nerves that are 
distributed to distant points — to the head, to the limbs, to the 
front and sides of the trunk — and to these parts the pain is re- 
ferred; thus "ear-ache" or "stomach-ache" or "sciatica" may 
be symptomatic of Pott's disease. The pain of Pott's disease 
is by no means constant; it is induced by jars or by sudden or 
unguarded movements. It is often worse at night, when, after 
the relaxation of the muscular tension that has protected the 
part, the unconscious movements during sleep cause discomfort 



28 OB TH OPE DIC S UB GEB Y 

or pain, and the child moans in its sleep, or is restless, and 
sometimes it wakes with a cry — "night cry." 

(6) Impairment of Function or Loss of Normal Mobility: Stiffness. 
— Stiffness of the spine is in part voluntary, in the sense 
that the patient adapts his movements and attitudes to the disease 
and pain — in order to avoid as far as possible strain and jar — 
but the essential and characteristic stiffness of Pott's disease 
is caused by the involuntary muscular tension and contraction 
of the muscles about the seat of disease. This reflex muscular 
spasm varies in degree, according to the state of the underlying 
disease. It may fix the spine or it may be evident only at the 
extremes of motion, but it is always present, preceding 
deformity and accompanying it until cure is established; thus 
it is the most important of the diagnostic symptoms of Pott's 
disease. 

(c) Weakness. — As the disease affects the most important 
support of the body, it is a direct as well as an indirect cause 
of weakness, and the more vulnerable the spine the more pro- 
nounced is this symptom; thus in a young child, whose spine 
is in great part cartilaginous, evidence of weakness is shown by 
the "loss of walk," the refusal to stand, and by the instinctive 
desire for support, at an early stage of the disease. 

(d) Change in Attitude: Awkwardness. — This really sums up 
the effects of the preceding symptoms, since it is evident that 
pain, weakness, and stiffness must cause a change in appearance 
and in the habitual attitudes of the patient. Such symptomatic 
attitudes may be almost diagnostic of the disease and of the 
part of the spine involved. 

(e) Change in the Contour of the Spine: Deformity. — The 
deformities of Pott's disease may be classified as follows: 

1. Bone deformity. 

2. Muscular deformity. 

3. Compensatory deformity. 

The characteristic angular projection due to destruction of 
bone has been described already. 

Muscular deformity is the distortion due to muscular spasm 
or contraction. Of this, the wryneck, symptomatic of cervical 
disease, and psoas contraction of disease in the lower region of 
the spine, are the most familiar examples. 

Compensatory deformity signifies the more general effect of 
the local disease and local distortion upon the spine as a whole 
(Fig. 5). Thus an angular projection must be balanced by a com- 



TUBERCULOUS DISEASE OF TEE SPINE 



29 



pensatory incurvation, and lateral distortion in one direction 
by lateral distortion in another. 

These three deformities are, of course, nearly related, and 
they are usually combined, although muscular distortion may 
precede the stage of bone destruction, 
while the compensatory changes are not 
immediately apparent. On the other 
hand, the secondary changes in the con- 
tour of the spine may catch the eye before 
the primary local deformity is detected. 

Lateral deviation of the spine is not 
infrequent; it may be a direct distortion 
at the seat of the disease, caused by the 
destruction of the side of a vertebral body 
(Fig. 22), but more often it is a secondary 
effect of such irregular erosion at one or 
the other extremity of the spine, or the 
effect of muscular contraction, or it may 
be due to simple weakness, in which case 
it is a transient symptom. 

Finally, even at the earliest stage of the 
disease, there is almost always a slight 
change in the outline of the spine due to 
local rigidity; the spine no longer forms 
a long, regular curve when the body is 
bent forward, but as one section remains 
more or less rigid while the other bends, 
the outline is broken at or near the seat 
of the disease (Fig. 7). 

Secondary or Complicating Symptoms, (a) Abscess.— This 
may, by its size or situation, cause peculiar symptoms. In the 
retropharyngeal space it may interfere with respiration and 
deglutition. In the thoracic region it might be mistaken for 
pleurisy or empyema, and when it forms a tumor in the iliac 
fossa it may interfere with locomotion. 

(b) Paralysis.— This is usually a late symptom, but if the 
disease begins in the centre or posterior part of a vertebral 
body it may implicate the spinal cord before deformity is 
apparent. 

Abscess and paralysis are symptoms that may be explained 
by Pott's disease, but other than by calling attention to disease 
of the spine as a possible cause of the complication, they do not 




A , direct deformity; 
compensatory deformity. The 
dotted line indicates the nor- 
mal contour of the spine. 



30 ORTHOPEDIC SUHOEBY 

aid one in determining the diagnosis; for this reason they are 
classed as secondary symptoms. 

General Symptoms. — Especial stress is laid by certain writers 
upon the diagnostic value of a slight but constant elevation of 
the temperature. This is usually present if the disease is active 
or when an abscess is approaching the surface, but the positive 
value of the symptom in early or quiescent cases is doubtful. 
One may expect also that a patient suffering from tuberculous 
disease of the spine will present some evidence of a painful and 
depressing affection, or some evidence of inherited or acquired 
weakness; yet it must be remembered that the absence of such 
general symptoms would not exclude Pott's disease. 




Normal contour and flexibility of the spine. 

The Contour and Flexibility of the Normal Spine. — In the 
enumeration of the early symptoms of Pott's disease, two have 
been noted as of especial importance — the impairment of normal 
mobility and the effect of the disease upon the contour of the 
spine and upon the attitudes of the patient. Therefore, in the 
study of normal spine the standard with which that suspected 
of disease must be compared, mobility and contour, at different 
ages and under different conditions should receive especial con- 
sideration. 

The spine as a whole is a flexible column presenting certain 
constant curves, forward in the upper, backward in the middle, 
and forward again in the lower region. These curves are essen- 



TUBERCULOUS DISEASE OF THE SPINE 31 

tially the effect of the force of gravity and of the action of the 
muscles in balancing the weight of the body in the upright atti- 
tude. In the adult they are practically fixed; in early childhood 
they can be nearly obliterated by traction in the horizontal posi- 
tion; and in infancy they do not exist. If the newborn infant 
is placed in a sitting posture the head falls forward and the 
spine bends in one long backward curve, characteristic of weak- 
ness. If when it lies on the back the legs are drawn down 




Incipient Pott's disease. Showing the break in the contour of the spine, of which the 
normal flexibility is but slightly impaired. 

from their habitual attitude of semiflexion, it will be noticed 
that the range of extension is somewhat limited because of the 
absence of the lumbar curve and the inclination of the pelvis. 
When the gain in muscular power is sufficient to enable the in- 
fant to raise and to control the head, the curve of the neck appears. 
Later, when the child stands, the erector spina? muscles hold 
the body upright against the resistance of the iliopsoas group 
and of the ligaments of the hip-joints; thus the lumbar curve 



32 



ORTHOPEDIC SURGERY 



and the inclination of thejpelvis result, and the normal contour 
of the spine is established. 

If from the odontoid process of the axis of a normal indi- 
vidual in the erect posture a line be dropped to the ground, this 
perpendicular or weight line, about 
which the weight of the body is bal- 
anced, will indicate the curves of the 
spine, and divide it into sections that 
correspond sufficiently well to function. 
The cervical curve ends at the second 
dorsal vertebra, the thoracic curve at 
the twelfth dorsal, and the lumbar curve 
at the sacrovertebral angle (Fig. 8). 

What has been spoken of as the 
normal contour of the spine varies con- 
siderably in the adult. It is affected by 
the occupation and by many other cir- 
cumstances; of this, the round shoulders 
of the cobbler or the weaver, the stoop 
of weakness, of old age, and the like are 
familiar examples; but in childhood dis- 
tinct variations from the normal contour 
almost always have a clearly defined 
pathological cause. As the normal con- 
tour is the effect of the balancing of the 
body in the upright posture, it is evident that if the outline of 
one part is permanently changed compensation for this change 
must be made in another part. Thus when deformity is well- 
marked, the normal curves of the spine are often completely 
reversed (Fig. 5), and even at an early stage of the disease the 
abnormal contour will often attract attention, long before the 
characteristic angular projection has become apparent. 




The divisions of the 



Divisions of the Spine. 



Although the spine is a flexible column whose outline changes 
with every movement and posture yet the range and character 
of this motion vary greatly in different parts. In the cervical 
and lumbar regions the range is extensive, because of the relatively 
large proportion of elastic intervertebral substance, because 
of the direction of the articular surfaces, and because the 



TUBERCULOUS DISEASE OF THE SPINE 



33 



centre of motion is near the middle of the body. Motion is 
very limited in the thoracic region, because the intervertebral 




Cross-section of the body of a child at the third dorsal vertebra. (Dwight.) 

disks are thin, because of the overlapping spinous processes, 
and because it forms a part of the rigid thorax. Where free 



34 ORTHOPEDIC SURQER1 

motion is essential to the habitual attitudes, interference with 
normal motion, and the other attendant symptoms of disease will 
be apparent earliest. Thus one more often has the opportunity 
for early diagnosis in disease of the lumbar and cervical regions 
because in the one the motions necessary in stooping, sitting, 
and standing are constrained, and in the other the neck is stiff, 
or the head is turned or drawn from the normal line. In the 
thoracic region early diagnosis is less often made, because in 
this section motion is so unimportant that its restraint may 
escape the attention of the patient or parent. In considering 
diagnosis, therefore, and, in fact, treatment and prognosis, one 
should divide the spine into three sections to correspond with 
function : 

1. The neck part, that allows free motion of the head, ending 
at the third dorsal vertebra. 

2. The rigid thoracic part, which includes the third and the 
tenth dorsal vertebra?. 

3. The lower part, made up of the two lower dorsal and the 
lumbar vertebrae, in which the principal movements of the trunk 
are carried out (Fig. 8). 

One must bear in mind the distribution of the nerves, because 
the characteristic pain is referred to their terminations, also, 
the parts in relation to the spine at different levels that may be 
implicated in the disease. Thus remembering that the symp- 
toms of Pott's disease are in general, stiffness, weakness, pain 
and deformity, one will always apply these symptoms to a par- 
ticular region of the spine, and will picture to himself the effect 
of such stiffness, weakness, and deformity at this or that vertebra; 
the effect of an abscess in this or that situation, and the area 
of paralysis that might be caused by pressure on the cord at 
one or another level. 

Landmarks. — The atlas is on a line with the hard palate. 

The axis is on a line with the free edge of the upper teeth. 

The transverse process of the atlas is just below and in front 
of the tip of the mastoid process. 

The hyoid bone is opposite the fourth cervical vertebra. 

The cricoid cartilage is on a line with the sixth cervical ver- 
tebra. 

The upper margin of the sternum is opposite the disk between 
the second and third dorsal vertebras. The junction of the first 
and second sections of the sternum is opposite the fourth dorsal 
vertebra. 



TUBERCULOUS DISEASE OF THE SPINE 35 

The^tip^of the ensiform cartilage is opposite the lower part of 
the body of the tenth dorsal vertebra. 

The anterior extremity of the first rib is on a line with the 
fourth rib at the spine, the second with the sixth, the fifth with 
the ninth, and the seventh with the eleventh. 

The scapula overlaps the second and the seventh ribs, its 
lower angle being opposite the centre of the eighth dorsal ver- 
tebra. 

The root of the spine of the scapula, the glenoid cavity, and 
the interval between the second and third dorsal spines are in 
the same plane. 

The most constant landmark from which to count is the spin- 
ous process of the fourth lumbar vertebra, which is on a line 
with the highest point of the crest of the ilium. The umbilicus 
is near the same plane. 

The Inclination of the Pelvis. — In the erect attitude the plane 
of the brim forms an angle of 50 degrees to 60 degrees with the 
horizon. 

The tip of the coccyx is opposite the lower border of the sym- 
physis pubis. 

Length of the Spinal Cord. — In the adult the spinal cord ter- 
minates at the lower margin of the first lumbar vertebra. At 
birth it extends to the third lumbar vertebra and its membranes 
to the second division of the sacrum. 

The Intervertebral Disks. — In the adult the intervertebral disks 
form 41.9 per cent, of the cervical, 26.4 per cent, of the dorsal, 
and 44.6 per cent, of the lumbar regions of the spine (Dwight). 

The character of the disease, its manifestations, and its effects 
upon the spine having been outlined, the student is now brought, 
as it were, into actual contact with the patient and his friends. 
And as Pott's disease is the most important of the chronic affec- 
tions of childhood, it will serve as a type to illustrate methods 
of examination and of treatment as applied in orthopedic practice. 

The Rational Signs. — The symptoms of Pott's disease vary 
decidedly, not only with the region of the spine involved, but 
also with the age and surroundings of the patient. Like other 
forms of tuberculous disease it is an insidious chronic affection, 
and its early symptoms may fail to attract attention, because 
they are irregular or intermittent. When the diagnosis is evident, 
however, the mother almost always remembers that "something was 
wrong," that the child was fretful and disinclined to play, that 
it liked to lie on the floor, that it was awkward in its movements, 



36 OB THOPEDIO S UB QER Y 

that it was troubled by a cough or indigestion, or by oppression 
of breathing. One, or many, of such symptoms may have ex- 
isted for months; but, as a rule, it is not until deformity appears 
that the child is brought for treatment. It is often after a fall 
or violent play that the evidence of pain or weakness can no 
longer be overlooked, so that injury is likely to occupy a promi- 
nent place in the history. 

History. — The account of the disease given by the parent is 
usually . indefinite and misleading. Certain points, however, of 
relative importance may be ascertained by the following questions : 

One asks if the immediate relatives of the child have suffered 
from phthisis or other form of tuberculosis, as this might indicate 
a predisposition to disease, and thus affect the prognosis. 

One asks if the child has been robust or the reverse, and if 
recovery from the ordinary ailments of childhood was prompt 
or tedious, in order that one may judge of the quality of the 
patient. 

One next asks, not "how long has the child been ill?" for this 
is usually understood to refer to the duration of the more decided 
symptoms, but "w hen was the child last perfectly well ?" One 
asks particularly as to the onset of the first symptoms whether 
it was sharp and decided, or gradual and ill-defined; if the symp- 
toms were preceded by contagious disease. This latter is an 
important question, because measles, for example, predisposes 
to tuberculous infection or at least to its local outbreak, and 
diphtheria is often followed by paralysis or by weakness that may 
simulate certain symptoms of Pott's disease. The character 
of the injury that almost every patient is supposed to have re- 
ceived is then investigated. It should be made clear whether 
the injury was the direct cause of the symptoms, or if it may 
have simply aggravated or brought to light the dormant disease 
or if, as is often the case, there is simply an indefinite remembrance 
of an injury which has no connection with the symptoms. 

To establish injury as the direct cause of symptoms, the patient 
must have been well at the time of the accident, the symptoms 
must have followed immediately and must have persisted since; 
and finally, the symptoms must be of a nature to be explained by 
a definite injury. 

By careful questioning one may usually determine whether the 
symptoms of which the patient complains are acute or chronic. 
This is of importance because tuberculosis is a chronic disease — 
one of the few chronic diseases of childhood— although its ex- 



TUBERCULOUS DISEASE OF THE SPINE 37 

acerbations may resemble the symptoms of acute disease or 
even injury. 

However important a correct history may be, it is upon the 
physical examination that the diagnosis practically depends. 

Physical Signs. — The physical examination begins with in- 
spection when one notes the general condition and the actions 
and postures of the patient; but the ultimate test is the com- 
parison of the contour and the mobility of the spine suspected 
of disease with the normal standard. 

Voluntary actions and attitudes are important, because they 
show the adaptation of the body to the disease, the conscious 
and unconscious efforts of the patient to guard the weak part 
from strain and from motions that caused discomfort and pain. 
Direct inspection, palpation, and the tests of voluntary and pas- 
sive motion are of still greater importance, because by such means 
one may demonstrate the presence of disease and localize it with 
accuracy. 

The examination must be purposeful. When one asks the 
patient to pick up a coin from the floor, it is to test the lower 
region of the spine for the symptoms of weakness and stiffness. 
The ability to perform the act with ease by no means excludes 
disease of the spine in the regions not especially involved in the 
movements of stooping or turning the body, although this would 
appear to be the general belief. 

Such tests must not only be purposeful, but they must be 
adapted to the age and intelligence of the patient. The child 
that refuses to pick up a coin will often gather up its clothing, 
because it wishes to be clothed again. If it will not stoop, it 
will rise usually if placed in the recumbent or sitting posture — an 
equally useful test. A child will walk toward its mother if placed 
at a distance from her. It will always turn its head toward 
her; thus voluntary motion of the cervical region may be tested 
by changing the mother's position, while the child is held by 
the examiner. Young children that struggle and resist passive 
motion if placed on the table, submit quietly when held in the 
mother's arms. 

Various simple and effective tests will suggest themselves 
to the examiner who has a definite purpose in view, but much 
patience may be required in early cases, and several examina- 
tions may be necessary before the presence or absence of disease 
can be definitely determined. It is important to remember 
that in childhood at least, abnormal symptoms always have a 



38 ORTHOPEDIC SURGERY 

cause; therefore, a patient should be kept under observation until 
the cause is discovered. 

Of all the early signs of Pott's disease muscular rigidity or 
reflex muscular spasm is the most important, since it precedes 
deformity and accompanies it until cure is finally established. 
It is a spasm that resists motion in all directions; thus it may 
be distinguished from the spasm or contraction of certain groups 
of muscles caused by irritation or inflammation not connected 
with the spine, for in such instances motion is limited only 
in the directions directly opposed by the muscular contraction. 
True reflex muscular spasm is quite independent of the will, 
and thus it may be distinguished from simple voluntary resist- 
ance on the part of the patient. 

The muscular rigidity is most marked in the neighborhood 
of the disease, but it extends to a greater or less distance accord- 
ing to the acuteness of the local process and the susceptibility 
of the patient. Even at an early stage the situation of the dis- 
ease is usually shown by a slight irregularity of the spine in the 
centre of the area made rigid by muscular spasm, as well as by 
the change of contour. This change in outline and in flexi- 
bility may be demonstrated by bending the patient forward. 
If the spine forms a long, even, regular curve, and if there is 
no evidence of pain or rigidity when such an attitude is assumed, 
Pott's disease is extremely improbable. If, on the other hand, 
the outline of the curve is broken; if the motion of one section 
of the spine is restrained by muscular rigidity, disease may be 
suspected; and if other evidence of tuberculous ostitis is present, 
the diagnosis may be made with certainty (Figs. 6 and 7). 

By a careful physical examination one may expect to detect 
Pott's disease at its inception and to fix upon its location, or at 
least upon the point suspected of disease. One will then ask 
one's self if tuberculous disease of the bodies of the vertebrae of 
this particular region will satisfactorily explain all the symptoms 
of which the patient complains; if, for example, the pain cor- 
responds to the distribution of the nerves; if restraint of function 
will explain the attitudes of the patient, and if the change in 
contour is significant of a destructive process. 

As has been stated the symptoms and the effects of the disease 
differ according to the function of the part of the spine involved, 
and the further examination should be conducted, therefore, from 
this standpoint. 



TUBERCULOUS DISEASE OF THE SPINE 



39 



The Regional Examination. 

1. The Lower Region. — Considering the regions of the spine 
in the order of liability to disease one begins with the lower sec- 
tion, comprising the lumbar and the two lower dorsal vertebrae, 
that more nearly correspond in shape and function to the lumbar 
than to the thoracic division. 





Disease of the upper lumbar region 
before the stage of deformity, showing 
abnormal lordosis. 



The same patient (Fig. 10) five years later, 
showing deformity. 



This is the region of constant and extensive motion; thus the 
painful rigidity, characteristic of the disease, is often marked 
long before the stage of bone destruction. 

The characteristic attitude of the patient is one of what might 
be called overerectness, and in many instances there is an in- 
creased hollowness (lordosis) of the back (Figs. 10 and 12); thus 
the prominent abdomen may first attract attention. The walk 



40 ORTHOPEDIC SURGERY 

is careful, and a peculiar tip-toeing step, the feet being slightly 
inverted to avoid the jar of striking the heels, is often observed; 
this is, however, not a peculiarity of disease of this region alone, 
but is rather an evidence that the spine is sensitive to slight jars. 
More characteristic of lumbar disease is a peculiar swagger 
explained in part by the exaggerated lordosis, and in part by the 
loss of the accommodative, balancing motion of the lumbar spine, 
as the weight falls alternately on each limb in walking. 

The increased lumbar lordosis, so characteristic of the early 
s!;age of the disease, is capable of several explanations. It is 
partly voluntary, as bending the body forward brings pressure 
upon the diseased vertebral body, so bending it backward re- 
lieves this pressure. It is partly involuntary, caused by the con- 
traction of the large muscular masses on the posterior aspect 
of the spine; and it is in part compensatory, as the slight psoas 
contraction which is often present has a tendency to tilt the 
pelvis forward, necessitating a greater compensatory backward 
inclination of the body. 

As the disease progresses the lumbar section becomes straighter, 
and finally it may project backward in the characteristic angular 
deformity. Yet even after the lordosis has been obliterated 
the backward inclination of the body still continues as a com- 
pensation for the change in balance, which the transformation 
of the forward curve to a posterior deformity has necessitated 
(Fig. 11). Thus overerectness or backward inclination of the 
body characterizes the disease of this region from its beginning 
to its end in uncomplicated cases. 

Slight psoas contraction as a part of the general muscular 
spasm about the diseased area simply increases the lordosis; but 
if the contraction is greater, when for example an abscess is pre- 
sent which involves the substance of the psoas muscles or forms 
a painful tumor in the pelvis, the erect attitude is no longer pos- 
sible. The thighs are drawn toward the body, and the body 
is inclined forward to relax the tension. As this greater con- 
traction, with the abscess that is usually its cause, is commonly 
unilateral the patient "favors" the flexed limb, and the resulting 
limp is often mistaken for a sign of hip disease. Unilateral 
psoas contraction is, in fact, so often present when the patient 
is first brought for treatment, that a limp and the accompanying 
inclination of the body may be considered as characteristic of 
disease of the lumbar region at a somewhat advanced stage 
(Fig. 13). 



TUBERCULOUS DISEASE OF THE SPINE 



41 



The location of the pain depends upon the distribution of the 
nerves that supply the diseased vertebra? or that pass in their 
vicinity; it may radiate over the inguinal region or backward 
to the loins or buttocks or down the front or back of the thighs 
to the knees. Painful "cramp" is sometimes a prominent'symp- 





Disease of the lumbar region. First 
symptom, pain in the knees. 



Disease of the lumbar region with right iliopsoas 
abscess and psoas contraction. 



torn; the limb is spasmodically drawn toward the body and the 
patient, seizing it with both hands, shrieks with pain. 

Lateral inclination of the body is often present particularly when 
the disease is at the lumbosacral articulation. It is usually a symp- 
tom of unilateral psoas contraction and abscess; it may be due 
also to unilateral contraction of the muscles of the back, or at 



42 



OR TH OPE DIC SURGERY 



a later stage it may indicate collapse or destruction of one side 
of a vertebral body. In other instances it is not a fixed attitude, 
but is simply a voluntary adaptation to weakness or pain; thus 
one may find a large abscess in one pelvic fossa unaccompanied 
by psoas contraction, while the body is inclined toward the oppo- 
site side, apparently because the weight is supported habitually 
on this limb. 

The stiffness, weakness, and pain, characteristic of disease in 
this region, are exemplified in many ways; for example, the child 
may be unable to turn in bed; it is slow and awkward in rising 

in the morning or in changing 
from an attitude of rest to one 
of activity. It often prefers to 
stand rather than to sit, because 
in the latter position more weight 
is thrown upon the sensitive ver- 
tebral bodies. When seated, par- 
ticularly when riding in a carriage 
or street car, the patient often 
sits upon the edge of the seat, the 
shoulders only touching the back, 
while the hands rest instinctively 
on the seat, partially supporting 
the weight and steadying the 
spine. 

Stooping, a posture that in- 
creases the pressure on the dis- 
eased vertebral bodies and which 
necessitates muscular tension and 
strain in regaining the erect posi- 
tion, is particularly difficult and 
it is always avoided by the patient if the disease is at all 
acute. For example, when the child is asked to pick up an 
object from the floor, it either refuses or it squats on the heels or 
drops upon the knees (Fig. 14) instead of flexing the spine as 
in health. Young children, having seized the object on the 
floor, regain the erect attitude by pushing the body up by the 
pressure of the hands on the thighs. If the child is placed upon 
the floor it will, if possible, seize the mother's skirts or will crawl 
to a chair or other object upon which the body may be drawn 
up by the arms, so that the discomfort caused by contraction 
of the back muscles may be avoided. 




Lumbar disease. The manner of picking 
up an object. 



TUBERCULOUS DISEASE OF THE SPINE 



43 



After the inspection and the observation of the movements 
and attitudes of the patient, the examination of the range of 
passive motion is made. The patient is placed at full length, 




Showing the rigidity of the spine before appearance of deformity. 
Fig. 16 




Test for psoas contraction. 



face downward, on a table, and the range of extension and of 
lateral motion is tested by lifting the legs and swaying the body 
gently from side to side (Fig. 15). The spine is so flexible in 



44 



OR THOPEDIC SURGERY 



childhood that rigidity even in the upper dorsal region may be 
demonstrated by this method, and in testing the lumbar region 
the thorax should be fixed by the hand. While the patient re- 
mains in this attitude, one should examine for psoas contraction. 
The pelvis is pressed firmly against the table with one hand, 
while the leg, held in the line of the body, is gently lifted by the 
other (Fig. 16). The normal range of hyperextension at the 
hip-joint should allow the knee to be lifted two or three inches 
from the table. Restriction of extension of both thighs, indicat- 
ing a slight degree of psoas contraction, is very common in lumbar 
Pott's disease; but when the restriction is marked, and especially 
if it is unilateral, a deep abscess may be suspected. Such uni- 




A method of demonstrating psoas contraction. 



lateral psoas contraction may be demonstrated by placing the 
child on the back, allowing the limbs to hang over the edge of 
the table, when the unaffected thigh will drop below its fellow 
(Fig. 17). 

As a rule, flexion of the spine is much more restricted in the 
early stage of the disease than is extension; this may be demon- 
strated by placing the child on its hands and knees, and lifting 
it from the floor, when the body, instead of bending over the 
supporting hands, retains almost its original contour (Fig. 18). 

As has been stated, even at an early stage of the disease one 
may detect often a slight fulness about the spinous processes 
or a slight irregularity in their line, about which the muscular 



TUBERCULOUS DISEASE OF THE SPINE 45 

spasm is most marked; this indicates the exact seat of the 
disease. Deep pressure on the spinous processes will often 
cause pain, and sometimes greater elasticity at this point may 
be demonstrated. Except in the hands of an expert, it is, how- 
ever, a test of comparatively little value; and again it may be 
mentioned that local pain and local sensitiveness to pressure on 
the spinous processes are not characteristic signs of Pott's disease. 




Disease of the lumbar region before the stage of deformity. A test for rigidity. 

Finally, one should examine for pelvic abscess. This may 
be suspected when unilateral psoas contraction is present in 
marked degree, although psoas contraction may be present 
without abscess, and abscess may be unaccompanied by psoas 
contraction when the substance of the muscle is not involved. 

The typical psoas abscess, as pictured and described, is a 
fluctuating tumor that suddenly appears on the inner side of 
the thigh, although it may have been many months in descending 
to this position from its original site. Demonstrable abscess 
is present at some time in at least 50 per cent, of the cases of 
lumbar disease, and its detection is a matter of importance, 



46 ORTHOPEDIC SURGERY 

since its subsequent behavior will often materially influence 
the treatment. The child is placed on the side, the thigh is 
flexed, and the hand is pressed gently down into the loin and 
iliac fossa. Sometimes the examination will be made easier 
by extending the limb and thus bending the spine forward to- 
ward the hand. Often in this manner one can make out peculiar 
sausage-like thickening on one or the other side of the spine, or 
a larger, rounded tumor in the iliac fossa, the presence of which 
which would not otherwise have been suspected. 

Diagnosis. — If a careful physical examination were made 
in all suspicious cases, by one at all familiar with the ordinary 
symptoms of Pott's disease, the field for differential diagnosis 
would be small indeed; but it would appear that such examina- 
tions are not made usually by the physician who is first consulted. 
One may learn, for example, that the child has been circumcised 
because of pain about the genitals, or because of weakness of 
the limbs, supposed to be due to "reflex irritation;" or if the 
patient is an adult, that he has been treated for sciatica, rheu- 
matism, or strain, long after the deformity even, would have 
been apparent had the back been inspected. 

Pott's disease is most often mistaken for some one of the fol- 
lowing affections: 

Lumbago.- — This may simulate some of the symptoms of Pott's 
disease of this region, but it is of sudden onset, usually accom- 
panied by local pain and sensitiveness of the muscles themselves. 

Strain of the Back. — This is often accompanied by stiffness 
and pain on motion, but, like lumbago, its onset is sudden and 
its cause is known. The pain is usually localized at the point 
of injury; it is relieved by rest, and the restriction of motion is 
in great degree voluntary. In Pott's disease the pain is neuralgic ; 
it is often worse at night and the rigidity is due to reflex 
spasm. 

Sciatica. — The pain of sciatica is most often unilateral; it is 
usually confined to the distribution of this nerve, which is often 
sensitive to pressure throughout its course. The pain of Pott's 
disease, if it is referred to the limbs, is usually bilateral and the 
nerve trunks are not often sensitive to pressure. In sciatica, 
movements of the limbs that cause tension on the nerve are often 
painful, while motion of the spine is free, or but slightly restricted , 
the reverse of the symptoms of Pott's disease. It is true that 
lateral deviation and even rigidity of the lumbar spine are some- 
times observed in cases of lumbosciatic neuralgia of long stand- 



TUBERCULOUS DISEASE OF THE SPINE 



47 



ing, but if the latter symptom is marked the diagnosis may 
be regarded as open to question. 

Spondylolisthesis. — This is a very uncommon affection in early 
life. It may simulate disease at the lumbosacral articulation. A 
description of its peculiarities will be found in Chapter II. 




Disease of the lower dorsal region. The earliest indication of deformity. 



Sacroiliac Disease is far more likely to be mistaken for disease 
of the hip- joint than of the spine; the pain and sensitiveness 
are usually localized about the seat of disease and the move- 
ments of^the spine are not restricted. 

Lumbago, sciatica, and sacro-iliac disease are extremely uncom- 
mon in childhood, and if supposed strains or injuries of the 
back cause persistent symptoms, the appropriate treatment 



48 ORTHOPEDIC SURGERY 

would be similar to that of Pott's disease; that is to say, support 
of the suspected part, until the cause of the symptoms is made 
clear. 

The attitude characteristic of Pott's disease of this region, 
the hollow back, the prominent abdomen, and the swaying gait, 
may be simulated by bilateral congenital dislocation of the hip, in 
which the pelvis is suspended at a point behind its normal 
position; but in this instance the gait and attitude have existed 
since the child began to walk, and the symptoms of the disease 
are absent. A similar attitude is sometimes caused by weakness 
or paralysis of the muscles of the back, as, for example, in the 
muscular dystrophies. In such affections there may be also a 
disinclination to stoop, and there may be limitation of motion, 
symptoms that bear a superficial resemblance to Pott's disease; 
but as there are no other signs of disease of the spine, it may 
be readily excluded. 

When psoas contraction is present the resulting limp, often 
accompanied by pain in the limb, is almost invariably mistaken 
for a symptom of hip disease. 

Although flexion of the thigh caused by psoas contraction is a 
common accompaniment of Pott's disease, it is not usually an 
early symptom; thus the history will probably call attention 
to symptoms referable to the spine, that have preceded it. 
Again, the limp of Pott's disease is caused simply by flexion of 
the limb. 

It is not as in joint disease, accompanied by pain on functional 
use. When, therefore, in the physical examination the tension 
of the contracted iliopsoas muscle is relieved by flexing the thigh 
still further, the other movements at the hip, abduction, adduc- 
tion, rotation, and flexion, are free and painless. Thus, hip 
disease, in which all movements are restrained in equal degree 
by muscular spasm, may be excluded readily, except, perhaps, 
in infancy. 

Hip Disease in Infancy. — At this susceptible age there is almost 
always sympathetic spasm of the lumbar muscles in acute 
affections of the hip, and similar spasm of the hip muscles may 
be present in Pott's disease of the lower part of the spine. 

Several examinations may be necessary before the exact loca- 
tion of the disease can be determined, and in doubtful cases 
the application of a temporary support to the back and thigh, 
such as a spica-plaster bandage to relieve the sympathetic spasm, 
is a useful aid in diagnosis. 



TUBERCULOUS DISEASE OF THE SPINE 49 

It has been stated that extension of the thigh only is restrained 
by psoas contraction. It will be evident, however, that the 
presence of a large and painful abscess in the pelvis or thigh 
may limit motion in other directions as well; but even in such 
cases at least one movement is unrestrained; thus disease within 
the joint may be excluded. 

Secondary Hip Disease. — In Pott's disease of long standing, 
complicated by abscess, in which the tissues about the joint 
are infiltrated or traversed by discharging sinuses, secondary 
infection of the hip-joint is not an unusual complication. In 
such cases, when the limb is distorted and when motion at the 
hip is limited by the sensitive and contracted tissues, it is not 
easy to determine the presence or absence of joint disease. Doubt- 
ful cases of this class should be treated symptomatically. 

Pelvic Abscess. — As abscess is such a common complication 
of Pott's disease, it will be necessary to consider abscesses of 
other origin, that may cause occasionally symptoms resembling 
somewhat those of disease of the spine. Such are the perine- 
phritic abscess, and, more rarely, that of appendicitis. They differ 
from the abscess of Pott's disease in that they are, as a rule, acute 
in their onset and are accompanied by constitutional symptoms 
and by local pain and tenderness. In such cases the motions 
of the spine may be restrained, but the restraint is in great degree 
voluntary, quite different from the rigidity due to disease of 
its substance. It is true that the pelvic abscess of Pott's disease 
which has become infected may cause constitutional symptoms, 
but the history of the disability and discomfort that must have 
preceded the abscess, together with the probable presence of 
deformity, will make the diagnosis clear. Chronic abscess in the 
pelvis of other than spinal origin may be the result of disease of 
the pelvic bones, or of the sacroiliac articulation, or of the hip- 
joint. It may be caused by the breaking down of lymphatic 
glands, or it may have its origin in inflammation about the uterine 
appendages, and cases of so-called idiopathic inflammation and 
suppuration of the iliopsoas muscle have been described. In 
childhood, chronic abscesses in this locality are almost always 
tuberculous in character, and are caused by disease of bone, either 
of the spine or of the pelvis. Disease of the spine can be deter- 
mined usually by the methods already indicated, but if the abscess 
is of other origin its exact cause can be decided in many instances 
only by an operative exploration. Abscesses of this character, 
of slow and apparently painless formation, may finally cause 



50 OR THOPEDIC S UB GEB T 

a swelling in the inguinal region or about the saphenous opening, 
that in the adult is not infrequently mistaken for hernia. In prac- 
tically all cases, however, the tumor of the abscess may be made 
out on palpation within the pelvis, and, although the contents 
of the external sac may be in part forced back into the larger 
reservoir, its reduction is very different in feeling from that of 
a true hernia. 

Peculiarities of Lumbar Pott's Disease in Infancy. 

Attention has been called repeatedly to the great importance 
of careful observation of the postures and movements of the 
patient, to the change in the contour of the spine, and particularly 
to the abnormal lordosis and peculiar attitude of overerectness 
in the early stage of disease. But the description of attitudes 
of standing and walking, and of the contour of the spine which 
is the result of the erect posture, does not apply to the infant 
in arms, nor can the spine be divided into contrasting sections 
for the purpose of differential diagnosis. In Pott's disease of 
infancy the muscular spasm is usually more intense and its extent 
is greater; the child screams when it is moved or when the diapers 
are changed. Slight irregularity of the spinous processes in- 
dicating the position of the destructive process is often evident 
and abscess is not unusual. There is usually no difficulty in 
determining the presence of disease even in very early cases, 
but, as has been mentioned, it is sometimes difficult to decide 
whether the lumbar spine or one of the hip-joints is involved. 

Pott's disease of infancy may be mistaken for acute rhachitis, 
or scurvy. The symptoms of such affections are, however, not 
limited to the spine, but involve to a greater or less degree the 
limbs and joints, indicating that the discomfort and pain are 
due to a general, not to a local disease. 

The Rhachitic Spine. — The deformity of the spine, caused by 
rhachitis, is not infrequently mistaken for the kyphosis of Pott's 
disease. 

It has been stated that when in early infancy the child is placed 
in the sitting posture the spine bends in a long, posterior curve, 
indicative of the weakness normal at this age. Such a curvature 
is characteristic also of acquired weakness and particularly that 
caused by rhachitis in early childhood. The weak child that has 
never walked or that has " lost its walk" sits much of the time in 
its chair, or is carried about on its mother's arms. In this posture 



TUBERCULOUS DISEASE OF THE SPINE 51 

the spine is habitually bent backward Soon a slight projection 
persists, even when the child is lying down. This usually 
increases in size and becomes more resistant, forming a somewhat 
rounded and rigid posterior curvature of the dorsolumbar portion 
of the spine. 

The diagnosis from Pott's disease should be made without 
difficulty, because the evidences of general rhachitis being 
present, the deformity is almost as much to be expected as 
would be distortions of the legs were the child walking. If 
the patient is placed in its habitual sitting posture it will be seen 
that the deformity is simply an exaggeration of a normal attitude. 
In this attitude the patient remains contentedly for an indefinite 
time, whereas if Pott's disease were present the child would lie 
on its back or abdomen. The projection is rounded, not angu- 
lar, and if the patient be placed in the prone posture the projec- 
tion may be reduced, in great part, by raising the thighs while 
gentle pressure is exerted upon the kyphosis. Finally, although 
such extension and pressure may cause- discomfort, there is com- 
plete absence of the muscular spasm characteristic of Pott's disease. 

It may be stated, then, that the rhachitic deformity is a rounded 
curvature of the lower part of the spine. Its cause is weakness 
and habitual posture. The rigidity depends upon the duration 
of the deformity. The pain, if the rhachitis be acute, is general 
and it is easily explained by the sensitive condition of the 
bones and joints. It is true that rhachitis and tuberculous dis- 
ease of the spine may be combined, but in such rare instances 
the symptoms of the more serious local disease will make them- 
selves evident as distinct from those of the general weakness. 

Recapitulation. — The more characteristic symptoms of disease 
of the dorsolumbar region may be summed up as follows: 

Increased lordosis or overerectness and a prominent abdomen; 
a cautious, constrained, or waddling gait; less often a lateral 
inclination of the body or a limp caused by psoas contraction. 

Stiffness of the spine, which makes bending or turning the 
body difficult. 

Pain referred to the back, to the inguinal region, or to the 
thighs, and in more advanced cases the characteristic deformity. 

Diagnosis. — The attitude may be simulated by congenital 
dislocation of the hips and by muscular dystrophy. 

The limp may be mistaken for that of hip disease. 

The pain and stiffness for sciatica, rheumatism, lumbago, 
or injury. 



52 OB THOPEDIG S UB GEB Y 

The abscess is to be distinguished from those from other sources. 

In young infants the symptoms may be simulated by hip disease 
and by acute rhachitis or scurvy. 

Finally, the deformity of the subacute form of rhachitis is to 
be distinguished from that symptomatic of bone destruction. 



Disease of the Thoracic Region of the Spine. 

The normal movement of this section of the spine, which in- 
cludes the third and tenth vertebra;, is as compared with those 
above and below it, slight; thus, disease of this region may not 
interfere to a noticeable degree with the general functions of the 
spine. 

As this part of the column curves backward, the deformity, 
often unattended by severe symptoms, is not infrequently mis- 
taken for round shoulders (Fig. 20). It seems probable, also, 
because of the normal backward curve, and because of the leverage 
exerted by the weight of the head and arms, that deformity quickly 
follows disease. At all events, patients are not often seen before 
it is present, so that the diagnosis is usually evident on inspection 
of the patient. 

The attitudes are not especially significant. If the lower part 
of the region is involved, and if the disease is at all acute, they 
are similar to those of disease of the lower region, viz., erectness, 
the peculiar, cautious, in-toeing step, and the disinclination 
to bend the body forward (Fig. 19). 

If, on the other hand, the upper part is affected, the attitude 
is often, particularly in young children, one of weakness; there 
is a slight forward inclination of the body, the head being tilted 
backward or inclined toward one side, and a peculiar shrugging, 
squareness, and elevation of the shoulders is often noticeable 
(Fig. 21). In many instances the apparent elevation of the 
shoulders is in reality caused by the deformity, which shortens 
the neck and lowers the head (Fig. 23). 

In this connection it should be mentioned that one of the second- 
ary effects of the disease, the so-called pigeon chest, may first 
attract the attention of the parent. The forward inclination of 
the spine causes a flattening of the upper part of the chest, while 
the sternum sinks downward and becomes prominent; thus, 
the anteroposterior diameter of the thorax is increased, and it 
is compressed from side to side, resembling very closely the 



TUBERCULOUS DISEASE OF THE SPINE 



53 



deformity of rhachitis. As the pigeon chest of Pott's disease 
is always secondary to the spinal deformity, its cause, of course, 
becomes apparent on examining the back. 

Of the early symptoms of disease of the thoracic region, pain 
and labored or "grunting" respiration are the most characteristic. 
Pain referred to the abdomen and to the front and sides of the 




Pott's disease of the middle dorsal region 
at an early stage, showing slight increase 
of the dorsal kyphosis, without noticeable 
change in the attitude. Contrast with 
Fig. 21. 



Disease of the upper dorsal region. 
Characteristic attitude. 



chest is usually an early and often a constant symptom; thus, 
persistent "stomach-ache" in a child should always lead to an 
examination of the spine. A "spasm of pain" is sometimes 
excited by lateral compression of the chest, as when the child 
is lifted suddenly by the parent. 



54 OB THOPEDIG SURGERY 

Of much greater importance, however, is the labored or grunt- 
ing respiration, which, indeed, is almost pathognomonic of Pott's 
disease. This "grunting" is caused by the interference with 
respiration, more particularly with the normal rhythmical move- 
ments of the ribs. The restraint is, in part, due to muscular 
spasm and to deformity and in part to the voluntary effort of the 
patient. The inspiration is quick and shallow, in great degree 
diaphragmatic, and expiration is accompanied by a sigh or grunt. 
This is caused apparently by a momentary closure of the larynx 
to resist the escape of air and thus sudden motion of the chest 
walls. Grunting respiration is, of course, an evidence of the 
more acute type of disease, but even in mild cases will be noticed 
when the patient is fatigued or during play. 

An aimless cough is often a symptom of disease of the upper 
dorsal region, and spasmodic attacks resembling asthma are 
not uncommon. 

In most instances the characteristic deformity will appear 
on examination, and in the exceptional cases in which it is absent 
a slight change in contour will be apparent when the trunk 
is flexed. In place of the long, regular curve of the normal 
spine a point where two distinct outlines unite will be observed 
— one of which may be curved, while the other is practically 
straight (Fig. 7). 

The presence of muscular spasm may be shown by sudden 
movement of the spine, and it may also be demonstrated in 
children by raising the legs and swaying the body from side to 
sile, as illustrated in the preceding section (Fig. 15). The change 
in the rhythm of respiration has been mentioned already. Al- 
though the respiratory movement of the entire thorax is lessened 
in range, the restraint does not affect all the ribs equally; those 
that articulate with the diseased vertebrae are often nearly motion- 
less, while the movement of those at a distance from the disease 
may approach the normal. 

In tracing the neuralgic pain to its source the sharp, downward 
inclination of the ribs must be borne in mind; thus, the cause 
of pain in the "stomach" must be looked for between the shoulder 
blades. 

As in the lumbar region, slight lateral deviation of the spine 
is not uncommon, and it may be accompanied by a noticeable 
twist or rotation so that the ribs on one side project slightly 
backward (Fig. 22). 

Li this region the spinal cord is more often involved than in 



TUBERCULOUS DISEASE OF THE SPINE 



55 



disease of other sections; thus, an awkward, stumbling gait and 
finally a "loss of walk" may be the symptoms that first attract 
attention. The paralysis of Pott's disease and its differential 
diagnosis are considered in more detail elsewhere. 

Abscess as a complication of dis- 
ease of the thoracic region cannot 
be demonstrated by palpation unless 
it has found an outlet between the 
ribs, but percussion will often show 
an area of dulness or flatness extend- 
ing from the diseased vertebra? 
toward the lateral aspect of the chest. 
This is due in part, however, to the 
inflammatory thickening of the tis- 
sues in the neighborhood. In rare 
instances the abscess may press 
directly upon the trachea or bronchi 
and cause spasmodic attacks of 
dyspnoea resembling asthma. 

Diagnosis. — It is hardly necessary 
to mention the list of affections that 
may cause pain in the chest or abdo- 
men; it is sufficient to state that 
such symptoms always require a 
physical examination. The same 
statement applies to irregular respi- 
ration, to cough, and to so-called 
asthma. 

Occasionally tuberculous disease 
of the thoracic section in adoles- 
cence is practically painless, and the 
resulting deformity is rather rounded 
than angular, so that it may be mis- 
taken for round shoulders. "Round 

shoulders" is, however, as a rule, of long duration. The exciting 
cause or causes of postural deformity, in occupation or other- 
wise, are indicated often by the history. The rigidity is less 
marked than in Pott's disease, and neuralgic pain is absent. 

The contour of the rhachitic kyphosis has been described. 
It should be evident that a more or less angular projec- 
tion in the upper part of the spine could not be rhachitic; 
and yet because of the absence of pain this diagnosis is made 




Marked lateral deviation of the spine 
with rotation. Deformity at the eighth 
dorsal vertebra. 



56 



ORTHOPEDIC SURGERY 



not infrequently, and as a consequence the activity of the tuber- 
culous disease may be increased by massage and exercises. 

Lateral deviation of the spine as a symptom of disease hardly 
could be mistaken for the ordinary rotary-lateral curvature, in 
which pain and muscular rigidity are absent. 

Acute affections within the chest, 'pleurisy, pneumonia,' and 
empyema, are sometimes accompanied by lateral deviation of 
the spine, but the sudden onset and the constitutional and local 




Double psoas contraction of an extreme degree and paralysis. The arms used as supports. 

symptoms that accompany such affections should make the 
cause of the deformity and pain evident. It is because these 
cases are sometimes sent to orthopedic clinics for braces that 
they seem worthy of mention. 

The abscesses in this region, as has been mentioned, cause 
usually dulness or flatness on percussion of the chest, and within 
this area friction sounds and rales may be heard. The tuber- 
culous fluid may remain indefinitely in the posterior mediastinum 



TUBERCULOUS DISEASE OF THE SPINE 



57 



and the area of flatness may extend beyond the axillary line, 
yet it may give rise to no symptoms. If the diagnosis of Pott's 
disease had not been made or if the presence of the abscess had 
not been determined by the previous physical examination, it 
might be mistaken, during an acute exacerbation of the disease 
or constitutional disturbance from other cause, for pleurisy or 
empyema or even for phthisis. In all cases, therefore, a careful 
examination of the chest should be made from time to time in 
order that the presence or absence of abscess may be recorded. 




Cervical disease with abscess. Characteristic attitude. 



Recapitulation. — Pott's disease of the thoracic region is often 
insidious in its onset, causing no positive symptoms before the 
stage of deformity. 

Its most characteristic symptoms are pain referred to the front 
and sides of the body and the grunting respiration. 

If the disease is progressive, weakness and rigidity are present. 
The attitude, when the disease is in the lower thoracic region, 



58 OR THOPED IC SURGERY 

resembles that of lumbar disease; if the upper part is affected 
the head is tilted somewhat backward and the shoulders appear 
to be elevated. 

In differential diagnosis one will consider the significance 
of pain, cough, or embarrassed respiration, and the affections 
for which abscess or paralysis might be mistaken. Also, round 
shoulders, rhachitic deformity, and lateral deviation of the spine 
as distinguished from the kyphosis of Pott's disease. 

2. The Upper Region. — The upper region of the spine, which 
includes the cervical and two of the dorsal vertebrae, corresponds 
in freedom of movement and in its contour to the lumbar region. 
For the purpose of study it must be divided into two parts. 
Of these, the superior or occipitoaxoid section is peculiar, in that 
it contains no vertebral body or intervertebral cartilage, and in 
that the movements of the head are carried out in special joints 
and are controlled by special muscles. 

Disease at this point is dangerous, because displacement or 
fracture of the weakened vertebrae may cause sudden death 
by pressure on the vital centres. 

Occipito-axoid disease is uncommon, and it is relatively more 
frequent in adult life than in childhood. 

Symptoms. — In a typical case the symptoms are neuralgic 
pain radiating over the back and sides of the head, following 
the distribution of the auricular and occipital nerves. The 
neck is stiff and the head may be fixed in the median line, the 
chin being somewhat depressed; but it is more often tilted to 
one side, simulating the attitude of torticollis (Fig. 24). 

The attitude and appearance of the patient, when normal move- 
ment of the neck is restrained by a painful disease, is character- 
istic ; the eyes follow one, or the body is turned, when the attention 
of the patient is attracted. The patient moves carefully, in 
order to avoid jar; often the chin is instinctively supported by 
the hand, and a favorite attitude is one in which the patient sits 
with elbows on the table, the hands supporting the head (Fig. 25). 
If the attempt is made to raise the chin, or to rotate the head, the 
patient seizes the hands of the examiner, and, it may be, screams 
in apprehension. There may be slight bulging and thickening 
of the tissues at the seat of disease. The affected vertebrae are 
usually sensitive to direct pressure, and not infrequently deep 
fluctuation in the suboccipital triangle can be made out. 

The atloaxoid junction lies just behind the posterior wall 
of the pharynx, on a line with the upper teeth. Here abscess 



TUBERCULOUS DISEASE OF THE SPINE 59 

often presents itself, occasionally early in the course of the disease, 
causing symptoms of obstruction, such as snoring, change in 
the quality of the voice, difficulty in swallowing, or spasmodic 
attacks of so-called croup. When abscess is present and when 
the disease is at all acute, the reclining posture sometimes 
aggravates the symptoms, so that "getting the child to bed" 
is often a tedious and difficult task. 



Cervical disease. A characteristic attitude. 

In certain cases one can determine whether the disease is of 
the occipitoatloid or of the atloaxoid articulation, but, as both 
joints are to a great extent controlled by the same muscles, this 
is often impossible. 

The uppermost joint, that between the atlas and occiput, 
permits the nodding movement of the head, or flexion and ex- 
tension on the spine; while the atloaxoid joint permits rotation 
of the atlas about the axis to the extent of about 30 degrees in 
either direction. 

If the disease be in the upper joint the nodding movements 



60 



ORTHOPEDIC SURGERY 



will be more restricted than those of rotation, and vice versa. 
The motion of the cervical region is very free; so that to make 
the test one must grasp the neck firmly in order to restrain motion 
except in the joint under examination. Because of this freedom 
of movement, restriction of motion of the upper articulations 
is often overlooked when the disease is of the subacute variety. 
The Lower Cervical Region. — The symptoms of disease of the 
lower cervical section, although similar in character, are often 
less marked than those of the upper region. The cervical spine 
becomes straighter, and often a slight backward projection or 
thickening indicates the position of the disease. The head is 
usually turned to one side by contraction of the lateral muscles in 




Disease of the middle cervical region at an early stage. 



an attitude of wryneck (Fig. 26). The pain is referred to the 
neck, to the sternal region, or down the arms, following the dis- 
tribution of the brachial plexus. 

In the more advanced cases one's attention may be attracted 
to the cervical region, because the neck seems short and because 
the head is tilted backward. The entire back shows a com- 
pensatory flattening, yet no deformity is apparent until the occiput 
is raised and drawn forward, when a shelf-like projection may 
be felt at what appears to be the extremity of the spine, but which 
is really an angular deformity at the third or fourth vertebra. 

This emphasizes the importance of a careful observation 
of the contour of the spine, and the necessity of explaining 



TUBERCULOUS DISEASE OF THE SPINE 



61 



to one's self every change from the normal that may be 
noticed. 

Disease at the cervicodorsal junction resembles in its symptoms 
that of the upper dorsal region. The head is usually tilted back- 
ward (Fig. 21) or it may be turned to one side. Disease at this 
point is often subacute in character, and paralysis from implica- 
tion of the spinal cord sometimes appears before deformity is 
apparent. Occasionally irregularity of the pupils is present. 

The spinous process of the seventh cervical or first dorsal 
vertebra is often prominent (vertebra prominens) in normal 
individuals, and it may be mistaken for the deformity of disease, 
especially when pain about this point is a symptom, as in hys- 




Deformity at the cervical vertebra indicated by the wrinkle in the neck. The attitude of 
the head and the compensatory projection in the lumbar region are characteristic. 

terical or hyperaesthetic persons. If such projection is symp- 
tomatic of disease there is almost always a slight compensatory 
flattening of the spine below the point and a certain degree of 
rigidity of the surrounding muscles. 

Diagnosis. — As stiffness and distortion of the neck are the 
most prominent symptoms of disease of this region, one must 
consider first the forms of torticollis for which it might be mis- 
taken. In typical torticollis the distortion of the head is caused 



62 ORTHOPEDIC SURGERY 

almost invariably by contraction of the muscles supplied by 
the spinal accessory nerve, the sternomastoid, and trapezius, 
thus, the chin is slightly elevated and turned away from the 
contracted muscle. 

Congenital torticollis, which has existed from birth, is not ac- 
companied by pain and it could hardly be mistaken for a symp- 
tom of disease. 

Acute rheumatic torticollis, "stiff neck," is sufficiently common 
to be familiar in its characteristics. It is of sudden onset, " in a 
single night;" the affected muscles are sensitive to pressure; the 
course of the affection is short and it is of comparative insignificance. 

A more persistent form of acute torticollis, characterized by 
muscular spasm and by local sensitiveness, sometimes accompanies 
enlarged or suppurating cervical glands; it may follow "ear-ache," 
"tonsillitis," "sore-throat," or any form of irritation about the 
pharynx. This form of wryneck is not only very painful, but 
it may persist indefinitely, and permanent deformity may result. 
The onset is usually sudden; the pain and sensitiveness are local 
and are confined, as a rule, to the contracted part. The sterno- 
mastoid and trapezius muscles are most often involved; thus, 
the wryneck is typical. If the tension be relaxed by inclining 
the head toward the contracted muscles, motion of the spine 
itself will be found to be free and painless; but if traction is 
made on the contracted muscles it causes discomfort, and it 
is usually resisted by the patient. 

In disease of the occipitoaxoid region the distortion of the 
head is by no means typical of sternomastoid contraction; it 
may be tilted up or down or laterally to an exaggerated degree. 
In other words, the wryneck of Pott's disease is an irregular dis- 
tortion, because it is not dependent on the contraction of a par- 
ticular muscle or muscular group. "In torticollis the chin is 
turned away from the contracted muscle, while in Pott's disease 
it is turned toward the contracted muscle." This is an axio- 
matic expression of the fact that the distortion of the head symp- 
tomatic of atloaxoid disease depends, in great degree, upon 
the spasm of the small muscles that directly control these joints, 
the recti and obliqui not upon the contraction of the mastoid 
muscle, as in the ordinary form of wryneck. Again, the con- 
traction, symptomatic of Pott's disease, of this or other regions, 
is the result of muscular spasm that checks painful motion. 
If the head be grasped firmly by the hands and if gentle trac- 
tion is made, the distortion may often be overcome without dis- 



TVBEBCTJLOUS DISEASE OF THE SPINE 63 

comfort to the patient. If similar traction is made upon the 
contracted muscles of acute wryneck the pain is increased and 
the patient protests. 

In disease of the middle cervical region, however, the distor- 
tion may resemble closely that of acute torticollis; for if the 
latter is caused by the irritation of inflamed or suppurating 
glands there is often sensitiveness to manipulation, with more or 
less general muscular spasm. In such cases the diagnosis may 
be impossible until apparatus has been applied to rest the part 
and to correct the deformity. 

As has been stated, the head may be tilted backward to com- 
pensate for deformity in the middle cervical region, and in some 
instances it may be drawn backward by spasm of the posterior 
muscles. Such a case might be mistaken for cervical opisthotonos, 
or posterior torticollis, which is sometimes seen in young infants 
suffering from exhausting diseases, basilar meningitis, and the 
like. In such conditions, however, the characteristic symptoms 
of Pott's disease are, of course, absent. 

The opposite attitude, viz., a forward droop of the head due to 
weakness of the trapezii muscles, is not uncommon as a sequence 
of diphtheria or other forms of contagious disease. This droop 
may be accompanied, also, by contraction of one of the sterno- 
mastoid muscles and by pain. In such cases the history of 
the preceding affection, the weakness or paralysis of other parts, 
as of the soft palate, of accommodation of the eyes and the like, 
together with the general bodily weakness should make the 
diagnosis clear. 

Injury of the upper segment of the spine, strain, contusion, 
or fracture, unless efficiently treated, may cause symptoms re- 
sembling very closely those of tuberculous disease; for example, 
pain, radiating over the back of the head, rigidity and deformity 
of the neck, and even infiltration and local tenderness about 
the injured part. Such cases, when seen several weeks or months 
after the accident, are puzzling, because one may be in doubt 
whether the symptoms were caused by a simple injury or whether 
tuberculous infection may have followed or preceded it. In 
such cases a positive diagnosis cannot be made until the effect 
of rest and protection has been observed — that is to say, suspi- 
cious cases should be treated as one would treat actual disease. 
If the case is simply one of injury recovery will be rapid and 
complete, while if disease is present the symptoms only will 
be relieved. 



64 ORTHOPEDIC SURGERY 

The occipitoaxoid articulations may be involved in acute ar- 
ticular rheumatism, in rheumatoid arthritis and the like. If the 
manifestations are general in character the diagnosis is, of course, 
easily made; but occasionally the joints at the upper extremity 
of the spine may be involved in what is apparently a local 
infectious arthritis, in which the symptoms are of sudden onset 
it may be accompanied by fever and constitutional disturbance. 
The sudden onset and rapid recovery if proper treatment is 
applied are the diagnostic points. 

Abscess in the cervical region is a secondary symptom, and al- 
though the change in the voice or the difficulty in breathing or 
swallowing may be the most noticeable symptoms, yet they are 
always accompanied by some of the characteristic signs of Pott's 
disease. Whenever the diagnosis of cervical disease is made one 
should examine the throat, and whenever a chronic retropharyngeal 
abscess is present one should look for the symptoms of Pott's 
disease. The diagnosis of the retropharyngeal abscess can be 
made only by inspection and palpation; therefore, one need only 
mention the fact that symptoms of obstruction in the throat, 
similar to those of abscess, may be caused by adenoid growths 
and by enlarged tonsils. 

Retropharyngeal abscess is by no means always symptomatic 
of Pott's disease. It may be one of the sequelae of contagious 
disease or a complication of pharyngitis. It is then rapid in its 
onset and is not accompanied by the symptoms of Pott's disease. 

Recapitulation. — If the disease is of the upper or occipito- 
axoid region the head is usually fixed in an attitude of deformity, 
which may be slight or extreme. If the disease is of the middle 
region, the attitude more often resembles that of ordinary torti- 
collis. In the lower region marked spasm of muscles is unusual, 
but the head inclines backward or toward one shoulder. 

The contour of the cervical spine changes as the disease pro- 
gresses; the normal anterior curvature is obliterated; thus, the 
head is pushed forward, while the dorsal section of the spine 
becomes flat or even incurvated in compensation. The seat 
of the disease is often shown by an area of thickening or local 
sensitiveness to deep pressure. 

Disease of the joints of the upper or occipitoaxoid section is 
often acute in onset, in some instances apparently a form of 
synovial tuberculosis, and abscess is a very frequent complica- 
tion. Differential diagnosis of disease in this region will include 
the consideration of the various forms of wryneck, cervical opis- 



TUBERCULOUS DISEASE OF THE SPINE 65 

thotonos, diphtheritic paralysis, and injury. Secondary abscess 
must be distinguished from simple retropharyngeal abscess and 
from other forms of obstruction in the throat. 

Diagnosis in General.— Weakness and the so-called "loss 
of walk" are well-known symptoms of Pott's disease, and on 
this account children suffering from different forms of weakness 
or paralysis are often sent to orthopedic clinics for the treatment 
of "spine disease." 

Certain forms of paralysis bear a superficial resemblance to 
some of the symptoms of Pott's disease; for example, pseudo- 
hypertrophic muscular dystrophy to the attitude caused by disease 
of the lumbar region, and diphtheritic paralysis to that of the 
dorsal region. Spastic paralysis, of cerebral origin, resembles 
somewhat the paralysis of Pott's disease, but it may be differen- 
tiated by the absence of pain by the history, and by what is 
apparent in most cases, the mental impairment. 

Primary spastic spinal paraplegia resembles the paralysis of 
Pott's disease more closely, but here, again, the essential symp- 
toms of a destructive disease of the spine are absent. The 
contractions . combined with the weakness and pain that some- 
times follow cerebrospinal meningitis may be mistaken for the 
symptoms of bone disease, but they are, as a rule, readily ex- 
plained by the history of the case. 

Forms of organic disease of the spine other than tuberculosis 
as, for example, malignant disease, syphilis, spondylitis defor- 
mans and the like in which the question in differential diagnosis 
is not of the presence or absence of disease but rather of its 
nature are described in Chapter II. 

The list of affections that has been considered in the differ- 
ential diagnosis is a long one, but it has been made up from 
actual experience. Most of the mistakes in diagnosis can be 
explained by carelessness or ignorance, or because of insufficient 
opportunity for examination; but in the earliest stages of the 
disease repeated examinations and even tentative treatment may 
be necessary before the diagnosis is confirmed. 

The Roentgen Ray Photography as a Means of Diagnosis. — Roentgen 
pictures are of comparatively little importance from the diag- 
nostic standpoint, but they may be of value as a means of deter- 
mining the exact extent of the disease. If the negative is well- 
defined, the diseased vertebrae are seen to be irregular in outline, 
or they may be lost in a peculiar blur. By counting from above 
and below the boundaries of the disease may be made out, but 

5 



66 



OR THOPEDIC SURGERY 



inferences as to its character and quality must be made from 
the rational and physical signs (Fig. 35). The tuberculin test 
is considered in Chapter V. 

The Record of the Case. — The history and the results of the 
examination of the patient should be recorded somewhat in the 
following order: 

1. The family and the personal history. 

2. The history of the disease, with especial reference to its 
mode of onset, its probable duration, to the noticeable symptoms, 
and to previous treatment. 

3. The physical examination. This should include the gen- 
eral condition of the patient, the height and weight, the attitude, 
the character of the disease, whether progressive, as indicated 
by muscular spasm and pain on motion, or quiescent, the pres- 
ence of abscess or paralysis as a complication, and, finally, the 
position and extent of the disease. This is best shown by a 



Nov. 2/900 



Dec./S. '900 



Tracings of the spine illustrating recession of deformity under treatment. 

tracing, made by means of a strip of lead or pure tin, of such 
thickness that it may be readily moulded on the spine and yet 
hold its shape when removed (Fig. 28). 

The tracing should be of the entire spine, made while the 
patient lies extended in the prone position, and the exact location 
of the most prominent spinous process should be marked upon 
it. In determining the position of the disease it is well to count 
the spinous processes from below upward, beginning with that 
of the fourth lumbar vertebra, which lies on a line drawn between 
the highest points of the iliac crests. There are other landmarks 
that are approximately correct. Sometimes the last rib may be 
traced to its origin; the scapula covers the second and seventh 
ribs, the root of the spine of the scapula and the middle point 
of the glenoid cavity being on a line with the third, and its in- 
ferior angle opposite the tip of the seventh dorsal spinous process. 
The upper margin of the sternum is opposite the interval between 



TUBERCULOUS DISEASE OF TEE SPINE 67 

the second and third dorsal vertebrae. In many instances the 
vertebra prominens and the spinous process of the axis can be 
identified. Such landmarks are, of course, somewhat displaced if 
the deformity is extreme, but they are always sufficiently correct 
to check errors in counting the spinous processes. 

The history furnishes a foundation on which treatment is 
conducted and from which its results may be determined. The 
study of final results has become of great importance in ortho- 
pedic surgery, and on this account the record should present 
the condition of the patient when treatment is begun, in a form 
that may be readily understood, not only by its writer when 
details have been forgotten, but by anyone who may in after 
years consult it. In this history the complications and incidents 
and the changes in the treatment should be noted at regular 
intervals while the patient is under observation. 

Treatment. — The general treatment of tuberculous disease is 
considered in Chapter V. Pott's disease is the most important 
of the tuberculous affections of the bones, and the importance of 
proper surroundings, proper food, sunlight, and, above all, open 
air both day and night, if possible, can hardly be exaggerated. 

The General Principles of Mechanical Treatment. — Under normal 
conditions the weight of the head and of the thoracic and abdom- 
inal organs tends to bend the spine forward and downward — a 
tendency that is resisted by the action of the muscles of the back. 
If the resistance is weakened, as in Pott's disease by the direct 
destruction of the weight-bearing portion of the spine, this ten- 
dency toward deformity is, of course, greatly increased. Thus, 
the pressure of the superincumbent weight upon the weakened 
part and the strain of motion are, from the mechanical stand- 
point the most important factors in the production of deformity. 

When the body is bent forward, as in the stooping posture, 
the intervertebral disks are compressed and the pressure upon 
the vertebral bodies is increased. When the body is held erect 
or is bent backward this pressure is lessened, and a part of the 
weight is transferred to the articular processes and to the poste- 
rior parts of the column. The object of a brace or other support 
is to hold the spine in the extended position, so that pressure 
on the diseased vertebrae may be removed. One aims to splint 
the spine as effectively as if it were broken, in order to relieve 
the discomfort and pain, so depressing to the patient, and to 
secure the rest that is essential to repair. 

The effectiveness of a particular splint or support, whether 



68 OB THOPEDIC S UB OEB Y 

applied to a broken bone or to a diseased spine, depends upon 
the area that it covers on either side of the part to be supported 
and upon the accuracy of its adjustment, as well as upon the 
damage that the part has already sustained, and the strain to 
which it still may be subjected. 

From this standpoint it is evident that it is difficult to apply 
effective support to the trunk because of its size, shape, and con- 
tents, and it is apparent also that the mechanical conditions 
are more favorable in some parts than in others. For example, 
the splint is likely to be effective when the disease is of the lower 
dorsal region, because its two extremities, attached to the pelvis 
and to the shoulders, are equidistant from the point to be sup- 
ported. These conditions are reversed in disease of the upper 
thoracic region, because the weight of the head and of the arms 
tends to increase the deformity, and because of the insufficient 
leverage that can be secured for the supporting appliance. The 
pelvis is the base of support for all forms of splints, and if it is 
smaller than the abdomen, as in infancy, the adjustment of effi- 
cient support is more difficult than in older subjects. 

In actual practice the treatment of Pott's disease is influenced 
by the age of the patient, the situation of the disease, the dura- 
tion of the deformity, and by many other circumstances, but 
the relative efficiency of braces or other appliances may be de- 
cided on purely mechanical grounds. Thus, as the ultimate 
deformity of Pott's disease is, in great degree, caused by the 
force of gravity acting on a weakened spine, the most effective 
treatment must be fixation in the horizontal position, for in this 
position the strain of use and the pressure of superincumbent 
weight can be removed completely. 

Horizontal Fixation. — Apparatus for this treatment must be quite 
independent of the bed on which it may be placed, and of such 
appliances several forms may be employed. 

The reclinationgypsbettes of Lorenz 1 is simply a posterior case 
of plaster-of-Paris enclosing the head and body. 

The Phelps bed is somewhat similar. A thin board is cut in 
the outline of the child's body and extended legs. It is padded 
with wadding and covered with cotton cloth; the patient is then 
placed upon it, and plaster bandages are applied to enclose the 
body and the legs. The front is then cut away, so that the patient 
may be removed from the bed for an occasional bath and change 
of clothing. 2 

1 Hoffa, Lehrbuch der Orthopudischen Chir., 3d., p. 324. 

" The Phelps Plaster-of-Paris Bed, Trans. Amer. Ortho. Assoc, 1891, vol. iv. p. 83. 



TUBERCULOUS DISEASE OF THE SPINE 



69 



The wire cuirasse has been popularized by Sayre; 1 it is an effec- 
tive appliance, although somewhat cumbersome and expensive. 

An effective and convenient form of support is the Bradford 
frame or stretcher. This is a rectangular frame a few inches 
longer and slightly wider than the patient's body. Over the 
frame covers of strong canvas are drawn tightly by means of cor- 



« 






I 



Bradford's bed-frame. (Bradford and Lovett.) 

set lacings or straps on its under surface, leaving an interval 
beneath the buttocks for the use of the bed-pan (Fig. 29). 

The efficiency of this appliance may be increased by changing 
it in several particulars, and the following description applies to 
the apparatus used by the writer: 

The stretcher frame is made of ordinary galvanized gas-pipe 
or steel tubing of a smaller diameter. It should be about four 




The modified frame with the bandage. 



inches longer than the child and about four-fifths as wide, the 
lateral bars corresponding to the articulating surfaces of the four 
extremities with the trunk. The ordinary dimensions are seven 
and one-half by thirty-eight inches, or the width to length about 
as one to five. 

At first thought it would seem that the side bars might cause 
uncomfortable pressure on the overhanging shoulders, but as 

1 Re"dard, La gouttiere de Bonnet, Chir. Orthopedique, p. 243. 



70 



OR THOPEDIC SURGERY 



the arms are set upon the middle of the lateral aspect of the trunk 
and thus on a considerably higher plane than the dorsum, there 
is but bare contact when the cover is fairly rigid. Before apply- 




The stretcherlrame. showing'the canvas cover and apron. 
Fig. 32 




The frame bent to assure overextension of the spine. The reces 
in this ease is shown by the tracings, Fig. 



>f deformity obtained 




The modified stretcher frame showing overextension of the spine, with traction for the 
head and limbs as applied for Pott's paraplegia. Caused by disease in the upper dorsal 
region. (See Fig. 56.) 

ing the cover one may with advantage wind bandages tightly 
about the frame at the point which is to support the trunk in 
order to make the support as unyielding as possible (Fig. 30). 
The cover should be of strong canvas suitably protected in the 



T UBEB CULO US DISEASE OF THE SPINE 7 1 

centre by rubber cloth. This is applied and is drawn tight by 
means of corset lacings and straps. Upon this two thick pads 
of felt are sewed; these should be about seven inches in length 
and about three-quarters of an inch in thickness, so placed as 
to pass on either side of the spinous processes at the seat of the 
disease, thus protecting them from pressure, fixing the part more 
firmly, and increasing the leverage of the apparatus. The child, 
wearing only an undershirt, stockings, and diaper, is placed 
upon the frame and is fixed there usually by a front piece or apron 
similar to that used with the spinal brace. As soon as the patient 
has become accustomed to the restraint one begins to over- 
extend the spine by bending the bars from time to time upward 
beneath the kyphosis with the aim, as has been stated, of actually 
separating the diseased vertebral bodies and obliterating all the 
physiological curves of the spine, so that the body shall be finally 
bent backward to form the segment of a circle. The greatest 
convexity is at the seat of the disease, and as the head and lower 
extremities are on a much lower level, an element of gravity 
traction is present in some instances, while the support of the 
spine, as a whole, is much more comprehensive than when the 
body lies upon a plane surface (Fig. 32). The gradual over- 
extension of the spine by bending the frame in this manner is 
so definite and simple that it may be easily carried out by the 
physician, and it may be exaggerated slightly, to compensate 
for the sagging of ' the cover. Thus, it is far more effective 
than any form of padding placed on a flat surface, or other 
form of support with which I am familiar. Upon this 
frame the child lies constantly, its clothing being made suffi- 
ciently large to include the apparatus, thus assuring additional 
fixation. Once a day or less often, the child is removed 
from the frame and is carefully turned, face downward, upon 
a large pillow; the back is then inspected, bathed with 
alcohol and powdered, and the apparatus is then reapplied. It 
is, of course, desirable to have two equipped frames, but this is 
by no means essential. 

The effect of the continued fixation upon the back is not merely 
to change the contour of the spine, but of the entire trunk as well; 
to flatten and broaden the body. This increase of the lateral 
at the expense of the anteroposterior diameter is quite the re- 
verse of the natural tendency of the deformity, and it is, there- 
fore, a favorable rather than an unfavorable effect of the treat- 
ment. The same tendency in the lower region may be checked 



72 



OR THOPEDW S UR GER Y 



by the use of a flannel binder, such as is ordinarily worn by 
infants. 

The method of attaching the patient to the frame varies some- 
what according to the situation and character of the disease. 
In ordinary cases, as has been stated, a canvas apron, similar to 
that used with the back brace (Fig. 43), is applied, and is buckled 
to the sides of the frame. If advisable the shoulders may be 
held down by bands crossing the chest or by axillary straps con- 
nected by a chest band. If still more effective fixation is de- 




A perfect cure obtained by the stretcher treatment. The situation of the disease 
is shown in the x-ray picture. Fig. 35. 

sired, as in disease of the upper dorsal region, the anterior shoulder 
brace, as used with the back brace (Fig. 41), may be attached 
to the axillary straps. In disease of the upper and middle re- 
gions of the spine restraint of the legs is not necessary, but in 
lumbar disease a broad swathe should be passed across the thighs, 
and if psoas spasm is present traction may be employed. 

If the disease is of the upper region and if the patient's 
head is of the long type, it is advisable to make a right angular 



TUBERCULOUS DISEASE OF THE SPINE 



73 



downward bend of the side bars above the seat of disease so 
that the occiput being on a lower level the proper pressure on 
the spine may be assured. 




An x-ray picture of the case (Fig. 34) before treatment. The situation of the disease at 
the junction of the first and second lumbar vertebrae is indicated by the lateral deviation, 
and by the approximation of the dotted lines 1 and 2 as compared to the others. 



74 OB TH OPE DIG S UB GEB 7 

In disease of the upper region of the spine a certain amount 
of traction is desirable to aid in the reduction of deformity and 
to prevent the patient from raising the head. This traction is 
usually applied by means of the halter as used with the jury- 
mast. The straps are attached to a crossbar at the upper ex- 
tremity of the frame, and traction may be made by simply tighten- 
ing them; or if the upper part of the frame is somewhat elevated, 
the weight of the patient's body makes the proper countertrac- 
tion. This position has the advantage, also, of allowing the 
patient a better opportunity to see what is going on about him 
(Fig. 33). 




The baby carriage as u<o<l in hospital practice for patients on the stretcher frame. 



In disease of the cervical region traction is usually of service 
and fixation of the head is always indicated in addition when 
the occipitoaxoid region is involved, either by sand-bags on 
either side, or, preferably, by some form of metal brace. 

Greater fixation of the spine may be desirable in cases of more 
acute disease. This may be attained by the use of a light back 
brace, or a plaster jacket, in connection with the frame. Such 
support should not be applied, however, until the recession of 
deformity, which is to be expected under treatment by the hori- 
zontal fixation and overextension, has been obtained (Fig. 28). 

As this frame is simply a horizontal brace the child may spend 
as much time in the open air as would be practicable were any 
other appliance used. 



TUBERCULOUS DISEASE OF THE SPINE 



75 



Personally I have never seen other than favorable results from 
this method of treatment. Pain and discomfort are, as a rule, 
relieved almost immediately, and there is a corresponding im- 
provement in the general condition of the patient. Meanwhile 
the growth of the trunk, which is so often checked by the disease 
and by the deformity, appears to progress with normal rapidity, 
so that the apparatus may be actually outgrown before the ter- 
mination of this part of the treatment. Horizontal fixation is, 




The Taylor brace'and 



support applied for disease of the upper dorsal region. 



of course, a treatment not complete in itself, since it must be sup- 
plemented by the usual supports when the erect attitude is 
again assumed. Its duration varies from six to eighteen months. 
The indications for its discontinuance are the correction of de- 
formity, the apparent quiescence or cure of the local disease as 
indicated by the physical signs, and by the behavior of the patient, 
who, as repair advances, becomes restless when removed from 
the frame, evidently desiring to sit and to stand. 



76 



OR T HOPE DIC SURGERY 



At this stage it is well to apply the ambulatory support some 
time before the patient is released from the frame, allowing little 
by little the changes in attitude and habits. If the plaster jacket 
is to be used it may be applied during longitudinal suspension 
or otherwise, after which the child is immediately replaced upon 
the frame, where the plaster is allowed to harden; thus it holds 
the spine in an attitude to which it has become accustomed. 
(Fig. 63). 

Ambulatory Supports. — The two types of ambulatory sup- 
ports are the steel brace and the plaster jacket. 

The Back Brace. — The spinal brace, or spinal assistant, as the 
original appliance of Dr. C. F. Taylor was called, consists essen- 
tially of two steel bars that are applied on either side of the 
spinous processes from the top to the bottom of the spine. At the 
seat of the disease pads are placed to provide for greater pressure 
and fixation, and to form a fulcrum over which the spine may be 
straightened or held erect, when the two extremities of the brace 
are firmly attached to the pelvis and to the shoulders. The 
Fio 3g attachment at the lower end is made 

>gr f - by means of a pelvic band of sheet 

steel (gauge 18) from one and a half 
to two inches in width, long enough 
to reach from one iliac spine to the 
other; it is placed as low as possible 
on the pelvis; in other words, just 
above the upper extremities of the 
trochanters. To this the uprights 
are firmly attached at an interval of 
from one and a quarter to one and 





The Taylor chest piece. Two triangular pads 
The Taylor back brace. (H. L. Taylor.) of hard rubber connected by a bar. 



TUBERCULOUS DISEASE OF THE SPINE 



77 



three-quarter inches from one another, so that the spinous 
processes may pass between them, while pressure is made 
on the lateral masses of the vertebrae. The uprights are 
made of varying strength, according to the age of the 
patient, usually about one-half an inch in width (of gauge 
8 to 12) and of such quality of steel that, although unyielding 
to the strain of use, it may be readily bent by wrenches, and thus 
accurately adjusted to the back. The uprights reach to the 
root of the neck, or to about the level of the second dorsal ver- 




Backward traction on the shoulder fixes the 
upper dorsal region. 



The anterior shoulder brace and its 
attachment. 



tebra; from this point two short arms of metal project forward 
and outward on either side of the neck, reaching to about the 
middle of the clavicles. To these, padded shoulder straps are 
attached, which pass through the axillae to a crossbar on the 
back brace; thus downward pressure on the shoulders is avoided 
and increased leverage is assured (Fig. 37). 

Opposite the area of disease two strips of thin steel about three 
inches in length are fixed; these are slightly wider than the up- 
rights and are perforated for the attachment of the pressure pads, 
which may be made of layers of canton flannel or felt, or un- 



78 OR THOPEDIC SURGERY 

yielding material, such as leather or hard rubber, may be used 
instead. The pads should project from a quarter to a half-inch 
in front of the uprights in order that firm and constant pres- 
sure, to the extent that the skin will tolerate, may be made at 
the seat of disease (Fig. 38). 

In measuring for this brace the patient is placed in the prone 
posture and a tracing of the outline of the back is made by means 
of the lead tape. This outline may be cut in cardboard and 
fitted to the back; in fact, if the mechanic is unfamiliar with 
the work, each part of the brace, uprights, pelvic band, etc., 
may be cut in cardboard and attached to one another to serve 
as a model. Before the brace is finished it should be applied 
to the back and should be adjusted carefully by means of wrenches. 
The pelvic band and the parts that come in direct contact with 
the skin are usually covered with leather, or, in the treatment 
of young children, with rubber plaster and canton flannel to 
prevent rusting. 

If the brace is applied before the stage of deformity it should 
follow the exact shape of the spine, but if deformity is present, 
particularly in disease of the thoracic region, it should be made 
somewhat straighter, in order to permit a gradual correction 
of the compensatory lordosis in the lumbar region, and for in- 
creased leverage above the deformity. As has been stated, a 
certain amount of recession of deformity can be obtained by 
rest in the horizontal position, and if practicable this improved 
contour should be attained before the brace is applied. The 
apparatus is held in place by an "apron" (Fig. 43), which covers 
the chest and abdomen, to which straps are attached. Ordin- 
arily this is made of strong linen or cotton cloth, but a canvas 
front shaped accurately to the body and strengthened with 
whalebone, is a more comfortable and efficient support. In 
applying the brace the pelvic band is first attached to the 
apron, then the straps in order, from below upward, and, finally, 
the shoulder straps. Each strap is tightened until the brace is 
firmly fixed in proper position. When a brace is properly applied 
and properly fitted it holds its place by friction, but when the 
disease is of the lower lumbar region, or if the brace has a 
tendency to upward displacement perineal straps should be used 
to hold the pelvic band firmly in its place (Fig. 38). At first 
the brace is removed once a day in order to wash and powder 
the back, the same care being observed in moving the child as 
in the treatment by the frame; but when the skin has become 



TUBERCULOUS DISEASE OF THE SPINE 



79 



accustomed to the pressure the brace should be removed only at 
infrequent intervals, and thus, if desirable, only under the super- 
vision of the surgeon. 

This description indicates the essential qualities of the back 
brace. It has been modified in various ways; for example, Dr. 
Taylor long since discarded the straight pelvic band in favor 

Fig. 42 




The Taylor back brace and head support combined with the Whitman anterior support. 

of one of a U-shape (Fig. 38). This makes the brace somewhat 
lighter and relieves the sacrum from pressure, but it does not 
add to its effectiveness. The efficiency may be increased, how- 
ever, by improving the attachment at its upper extremity, as 
is illustrated in Fig. 39, in which two triangular pads of hard 
rubber connected by a metal bar are employed. 

This is an improvement on the simple shoulder straps of the 
original brace, but it does not provide the quality of support and 
fixation that is desirable when the disease is of the upper or 



80 



ORTHOPEDIC SURGERY 



middle segment of the thoracic region. In such cases the upper 
part of the chest is flattened, the inclination of the ribs is increased, 
and the shoulders droop forward, carrying with them the scapulae. 
Thus, the weight and the strain of the motion and use of the arms 
tend to increase the deformity. 

In health direct forward or reaching movements of the arms 
are always accompanied by an increase in the posterior curvature 
of the dorsal spine. On the other hand, if the shoulders are 




The anterior shoulder brace. 



The scapular pads. 



drawn backward and held in this attitude, the curvature of the 
spine is lessened and the chest is elevated and expanded (Fig. 
40). 

In the treatment of disease of the upper dorsal region it should 
be the aim, in the application of a brace, to follow this indication 
and to apply pressure directly upon the extremities of the shoulders 
to assure the greatest possible fixation of the spine and to restrain 
the movements of the arms that tend to increase the deformity. 

The diagrams illustrated in Fig. 41 show how such support 
may be applied. Two saucer-shaped plates of hard rubber or 
padded metal (Fig. 42) cover the heads of the humeri and are 
joined by a rigid bar of steel, which passes across but does not 
touch the chest. On the back brace are placed two triangular pads 



TUBERCULOUS DISEASE OF THE SPINE 



81 



of similar construction, which cover and press upon the scapulae. 
These pads are, however, not essential and are often omitted. 
The back brace is applied, the shoulders are then drawn back- 
ward and the shoulder-cups are firmly attached by straps to the 
neck bars of the brace above, and by axillary bands below in 
the usual manner. By this means the thorax is elevated and 
the spine is more effec- 
tively fixed, while direct 
movement of the arms 
forward is made impos- 
sible. It would seem 
that such restraint would 
be irksome to the patient, 
but in an extended use 
of the apparatus this has 





The loop head support. 



Disease of the middle cervical region, showing 
the deformity and attitude. This patient had been 
paralyzed for one year before treatment was begun. 
(See Fig. 47.) 



never caused complaint- In many instances, even when the dis- 
ease is as low as the tenth dorsal vertebra, it may be used 
with advantage, but it is especially indicated when the disease 
is in the neighborhood of the seventh dorsal vertebra. In con- 
nection with the shoulder brace it is usually advisable to apply 
a support beneath the chin to prevent the forward inclination 
of the neck and to tilt the head somewhat backward. A very 



82 ORTHOPEDIC SURGERY . 

simple and inoffensive support of this character is a loop of 
steel surrounding the neck and attached by screws to a back 
bar on the brace (Fig. 45). If a more efficient brace is required, 
as when the disease is of the upper dorsal or cervical regions, 
the Taylor head support should be used. This is an oval 
ring of steel which may be clasped about the neck by means 
of a lateral hinge. . On the front a cup of hard rubber sup- 
ports the chin and behind the ring fits upon an upright pivot 
that may be raised or lowered upon a crossbar on the upper 
part of the brace; free lateral motion is allowed, or it may be 
checked by means of a screw (Fig. 47). 

If absolute fixation of the head is indicated, as in disease at 
or near the occipitoaxoid region, two steel uprights may be at- 
tached to the back of the ring; these are bent to fit the posterior 
and lateral aspect of the head closely, and a band of webbing 
is passed from one upright to the other and about the forehead. 

In applying the support the chin should always be tilted slightly 
upward in order to throw the weight of the head backward 
(Fig. 47). The adjustment of the head support is made easier 
if the pivot is attached to the upright by means of a ball-and- 
socket joint (Shaffer) (Fig. 37) that may be regulated by a screw 
and key; this arrangement is of service when the head is dis- 
torted, but it is by no means necessary. 

When the Taylor head support or similar appliance is used 
the greater part of the pressure is sustained by the chin, which 
may, after a time, undergo an unsightly recession. It may be of 
advantage, therefore, in such cases, and particularly when restraint 
of the motion of the neck is desirable, to transfer this pressure to 
the forehead and occiput by extending the back bars upward 
over the back of the head, as in Fig. 54. 

A jury-mast may be used to support the head also; its adjust- 
ment will be described in connection with the plaster jacket, with 
which it is usually associated (Fig. 48). 

The Plaster Jacket. — It was claimed at one time that a plaster 
jacket applied while the body was partially suspended would 
actually relieve the weakened area of superincumbent weight by 
holding the diseased surfaces apart. This is not the fact. The 
jacket supports the spine as does the brace by holding it in the 
erect or extended position. One is a circular and the other is a 
posterior splint. There is this difference, however: the brace 
fits the spine accurately and holds its place by pressure and friction ; 
the jacket is held in place by the support of the projecting pelvic 



TUBERCULOUS DISEASE OF THE SPINE 



83 



bones; it lacks the accuracy of adjustment of the brace at the 
seat of disease, but, on the other hand, it provides a solid support 
on the front and sides of the body. 

Each appliance has advantages and disadvantages that become 
apparent in the treatment of certain phases of the disease or con- 
ditions of the patient. 

Fig. 47 Fig. 48 




The Taylor brace and head support applied 
to the patient shown in Fig. 46. 



The Taylor brace with jury-mast. 



The plaster bandage is a simple support, whose efficiency 
depends upon the accuracy of its adjustment to the irregularities 
of the body, and upon the leverage that it exerts above and below 
the weakened part. It should be applied while the body is held 
in the best possible position; its inner surface should be smooth, 



84 OB THOPEDIC S UB GEB Y 

and the bony prominences that are exposed to friction and 
pressure should be protected. 

A seamless shirt should be worn; these are made in several 
sizes and are sold by the yard at a low price. The shirt should fit 
the body closely and should be long enough to reach to the knees. 
On the front and back bands of linen or China silk or other 
material, about three inches in width and three feet in length, 
should be placed beneath the shirt. These bands, or, as Lorenz 
calls them, "scratchers," are for the purpose of keeping the skin 
clean. The patient is then placed upon a stool, and the halter of 
the suspension apparatus is carefully adjusted; the arms are ex- 
tended over the head and the hands clasp the straps or rings; 
thus, the chest is expanded to its full limit. Sufficient tension 
is made upon the rope to partially suspend the body and to draw 
the spine into the best possible attitude; in most instances the 
heels should be slightly lifted from the stool. 

Dr. Sayre, to whom we are indebted for the exposition of this 
valuable means of treatment, insisted that the sensations of the 
patient should be the guide and that traction should be made 
only to the point of comfort. This is a valuable indication in 
the treatment of the adult, but it is not often of service in child- 
hood. 

Before applying the plaster bandage pieces of piano felting or 
similar material of sufficient thickness are placed about the anterior 
pelvic spines, over the upper part of the sternum, and a thin 
strip is sometimes used to cover the spinous processes. Finally 
long pads of saddler's felt, or of other material of sufficient thick- 
ness, are applied on either side of the prominent spinous pro- 
cesses to project them from friction and to provide greater pres- 
sure and fixation at the seat of disease. In the treatment of 
adolescent or adult females the breasts should be covered with 
a layer of cotton, which may be removed later if necessary, 
to prevent pressure. The "dinner pad" is now not often used, 
except in the treatment of adults and in certain cases in which 
the abdomen is retracted. In childhood the abdomen is usually 
prominent, and in most instances no extra space is required. 
Occasionally, however, one is told that the patient complains 
of discomfort after meals, evidently due to constriction, and in 
such cases proper allowance must be made. The pad, which 
is supposed to represent the space necessary after a full meal, 
is made by folding a small towel into the shape of a sandwich; 
this is attached to a bandage and is placed beneath the shirt 



TUBERCULOUS DISEASE OF THE SPINE 85 

just below the ensiform cartilage; when the jacket is completed 
it may be drawn out by means of the hanging bandage, leaving 
the additional space for emergencies. 

The materials for the jacket should be of the best. Fresh 
dental plaster should be rubbed by hand into strips of crinoline, 
free from glue. The bandages should be from three to five 
inches in width and six yards in length, from three to six being 
required for a jacket, according to the size of the child. They 
should be placed on end, in a pail of warm water, one at a time 
as they are used. No salt or alum should be used to hasten the 
setting of the plaster; in fact, if such aid, is necessary it is unfit 
for use. When the bubbles have ceased to rise the bandage is 
squeezed gently until no water drips from it, and the loose threads 
are removed from the ends. 

One person should sit behind the patient and one in front, 
while the third may hold the rope and check the swaying of the 
body. The one who sits behind the patient may clasp the child's 
legs between his knees and thus assure better fixation of the 
pelvis. The pads are held in position until they are fixed by the 
plaster bandages, which should be applied with a slight and even 
tension. 

As a rule, the jacket should be of uniform thickness through- 
out. This thickness need not exceed one-eighth to one-fourth of 
an inch, and it may even be lighter in certain cases. It is well 
to make the first turns about the waist, and to use the first band- 
age about the pelvis, since the pelvis is the base of support; and, 
as the most important point for counterpressure is the chest, this 
part should be made especially strong and resistant. 

During the application of the jacket it should be rubbed con- 
stantly in order that the different layers of bandage may adhere 
to one another, and that it may fit the projections of the pelvis 
and body closely. Meanwhile the attitude of the patient should 
be carefully watched, in order to prevent lateral inclination of 
the body. In some instances it is possible to lessen the deformity 
by the extension and by backward traction on the shoulders and 
forward pressure on the trunk while the jacket is hardening. 

When the jacket is nearly firm it should be trimmed. In many 
instances this may be done while the patient is in the swing, but 
if he is fatigued he may be placed in the recumbent posture. 

As a rule, the front of the jacket should reach from the upper 
margin of the sternum to the pubes; behind, from about the 
midline of the scapulae to the gluteal fold; laterally, it should be 



86 



OB THOPEDIC S UB GEB Y 



cut away sufficiently to prevent chafing of the arms; and on either 
side of the pubes an oval section is cut out, to allow for the flexion 
of the thighs in the sitting posture. Particular attention is called 
to the importance of making the jacket as long as possible, so 
that the abdomen may be contained within it instead of being 



Fig. 50 




The plaster jacket, illustrating the 
arrangement of the shirt. 



The plaster jacket supporting the abdomen. 
The cleansing bandages are not shown. 



forced out beneath its lower border (Fig. 50). After the appli- 
cation of the jacket the patient should remain in the recumbent 
posture for at least half an hour or longer, as it does not become 
absolutely firm for several hours. The shirt is then drawn up over 



TUBERCULOUS DISEASE OF THE SPINE 



87 



the jacket and is sewed to the neck portion; this adds much to neat- 
ness and cleanliness. The shirt must be drawn tightly about the 
neck, in order to guard the body from the crumbs or other objects 
that may fall beneath the jacket, and in many instances a special 
protector in the form of a wide collar bib may be used with 
advantage. 

The upper and lower ends of the cleansing bandages are joined 
to one another with tape, and with them the skin is carefully 
rubbed twice daily. When soiled they may be replaced. 




The jury-mast and the anterior support. 

It may be mentioned in this connection that even the slightest 
excoriation or irritation of the skin beneath the jacket can be 
detected by the peculiar odor. Of this parents should be in- 
formed, so that it may be cut down and the source of the irritation 
removed at once. With ordinary care 'sores," the bugbear of 
the plaster jacket, may be avoided or so quickly detected that 
they are of little consequence. 

If the disease is of the middle region of the spine, backward 
traction on the shoulders is indicated by means of the anterior 
shoulder brace described in connection with the spinal brace 



ORTHOPEDIC SURGERY 



(Fig. 51); or, if this is not at hand, padded straps may be passed 
about the shoulders and attached to buckles placed on the back 





Illustrating fixation of the head in the overextended attitude. 

of the jacket. Traction applied in this manner aids in prevent- 
ing deformity and assures better expansion of the chest. 



TUBERCULOUS DISEASE OF THE SPINE 



89 



In many instances a head support is required, and it is, of 
course, always indicated in disease of the upper dorsal and cer- 
vical regions. For this purpose a jury-mast or a posterior sup- 
port may be employed. 

The jury-mast should be of tempered steel, strong enough to 
hold its shape under the tension of the halter (Fig. 52). Its base 
should be incorporated firmly in the jacket below the seat of the 




A fixation support for the head. 
This may be used with the brace or 
with the jacket. 



Front view of the same patient. 



disease; it should be long enough to reach well above the head, 
and the crossbar should be placed directly over the ears (Fig. 56). 
The halter should be applied with as much tension as can be 
borne comfortably by the patient, so that the weight of the head 
may be at least partly supported. The straps should be ad- 
justed to tilt the chin slightly upward, the aim being to draw the 
head backward and thus to extend the spine. In disease of the 



90 



OR TH OPE DIC SURGERY 



cervical region the crossbar should be fixed to check lateral mo- 
tion of the head, but this is unnecessary when the disease is at 
a lower level. 

If more complete fixation of the head is desired, or if the jury 
is ineffective, an appliance similar to that shown in Fig. 51 may 




ii icnt i> shown in Kit-'. 38. 



be used. This consists of two light steel bars, incorporated like 
the jury-mast in the jacket, and adjusted to the neck and back 
of the head. Their upper extremities are joined by a band of 
light steel of U-shape, long enough to reach from ear to ear, the 
circumference being completed by a band of tape across the fore- 
head. In certain instances additional straps may be placed be- 
neath the chin and the occiput, as in Figs. 54 and 55. In this 
connection it may be stated that the support provided by the jury- 
mast is only effective when it is carefully adjusted and carefully 
watched. In most instances, therefore, a rigid apparatus, though 
less comfortable, is to be preferred. 



TUBERCULOUS DISEASE OF THE SPINE 



91 



The Application of the Jacket in the Recumbent Posture. — The 
jacket may be applied while the patient lies extended in the prone 
posture, by the hammock method suggested by Davy, of London. 

A long narrow strip of cotton cloth is passed under the shirt 
and is drawn tight enough, by means of a pulley or by manual 
traction, to support the child in the proper attitude, preferably, 
of course, in overextension. An opening is cut for the face, and 
if advisable, traction may be made on the arms and legs of the 
patient. The bandages are then applied in the ordinary manner, 
after which the cloth may be cut short at one end and removed 




The application of the jacket in the recumbent posture by means of the Goldthwait 
appliance: A, the support, similar to that upon which the patient is lying; B, two thin 
bands of steel, similar to those used in the Taylor brace. 



This method is of service in the treatment of weak or para- 
lyzed patients, but the adjustment is somewhat less satisfactory 
than by the ordinary method in that the fixation of the thorax 
is less accurate. The jacket may be applied in the supine posture 
by means of the Goldthwait apparatus. This may be employed 
with advantage in the routine application of the plaster jacket, 
and it has supplanted in some degree the suspension method. 

It consists essentially of a support (Fig. 57) carrying on its 
upper extremities two thin strips of perforated metal. To these 



92 



ORTHOPEDIC SURGERY 



strips felt is attached, forming pads similar to those used on the 
back brace. The patient is then placed with his back resting on 
the pads at the seat of the disease. The buttocks and the head 
are allowed to sink downward to the point of toleration; thus an 
extending force is exerted on the spine. The plaster bandages 
are then applied in the usual manner about the body on either 
side of the support. When it is completed the patient is lifted 
from the support, the pads being included, of course, in the jacket. 




R Tunstall Taylor's apparatus for the application of the plaster jacket in the recum- 
bent posture, consisting of an adjustable back Buppoii ami pelvic rest connected by a 
sliding bar. (See Fig. 59.) 

Fig. 59 




The Taylor appliance in use, showing the hyperextension of the spine. The plaster 
jacket having been applied, the back rest is removed by pressing the bandages from 
side to side or by enlarging the opening. If desirable, the defect is then concealed by 
a turn of plaster handage. 

An opening remains at this point that may be closed by an addi- 
tional bandage. 

Other supports of a similar nature are in use, but as they do 
not differ from it in principle a detailed description is unneces- 
sary (Figs. 58 and 59). 

If the deformity is of recent origin it may be actually corrected 
by the leverage exerted, but in most instances the hyperextensioD 
takes place in the unaffected parts of the spine, particularly in 



TUBERCULOUS DISEASE OF THE SPINE 



93 



the lumbar regions. Thus the correction is apparent rather 
than actual. In order to prevent this and to exert more effective 
leverage on the deformity Goldthwait uses the apparatus illus- 
trated in Fig. 60. 




Goldthwait's portable frame for applying the plaster jacket. 
Fig. 61 




The plaster jacket 



supine posture by means of the 
apparatus. 



er-Goldthwait 



The patient lies on two malleable steel bars fitted to the lumbar 
region reaching only to the apex of the deformity. The plaster 
bandages forming the lower part of the jacket having been ap- 
plied the upper portion of the trunk is allowed to sink downward 
to the point of toleration and the jacket is then completed. The 
steel bars which have prevented the upward arching of the 
lumbar region of the spine are then withdrawn. The Metzger 



94 



OR THOPEDIC S UR GER Y 



apparatus, of which that last described is an adaptation, which 
permits longitudinal traction as well as direct leverage, is shown 
in Figs. 61 and 62. 

The Application of the Jacket to Patients Who Have Been Treated 
on the Stretcher Frame. — A satisfactory method of applying a 
plaster jacket to young subjects, when the deformity has been 
corrected in whole or in part by recumbency on the frame in the 
overextended position, is the following : The patient is suspended 
face downward in the horizontal position by two assistants, one 
holding the arms and the other the thighs; thus, a certain amount 
of traction is exerted, while the weight of the body tends to over- 
extend the spine. 

In this attitude a jacket is quickly applied, and the child is at 
once replaced upon the frame, which has been protected by a 
rubber sheet (Fig. 62). The plaster jacket, during the hardening 




The stretcher frame on which the patient is replaced while the jacket is hardening 

process, must conform to the habitual posture of recumbency. 
The pressure pads of the frame indent the bandage on either 
side of the spinous processes (Fig. 63), and thus afford better 
support and fixation. This is a very satisfactory method of ap- 
plying the jacket in this class of cases, because it is not neces- 
sary to retain the child in an uncomfortable position while the 
bandage is hardening, and because accuracy of adjustment in 
the best possible attitude is assured. 

For the routine application of the plaster jacket vertical sus- 
pension is t"> be preferred, because in this attitude the support 
may be more accurately adjusted. The hammock method and 
that just described are of particular service in the treatment of 
young subjects. The supine posture may be selected with advan- 
tage when the spine is sufficiently flexible at the seat of disease 
to permit a certain degree of correction or if the patient is weak 
or timid. 



TUBERCULOUS DISEASE OF THE SPINE 



95 



As a rule, a jacket may be worn for two months, although not 
infrequently it may remain for six months, or even longer, and 
yet be fairly efficient. Usually one jacket is removed and an- 
other applied on the same day, but if the skin is at all sensitive 
it is well, after the washing and powdering, to reapply the old 
jacket, closing it with adhesive plaster, and allow an interval of 
a few days before applying the permanent one. 




Jacket applied by the stretcher method, showing the depressions on either side 
caused by the frame pads. 

The Plaster Corset. — In the stage of recovery the jacket may 
be replaced by a corset. A jacket, made and trimmed as already 
described, is cut down the centre and removed from the body. 
It is carefully readjusted to its former shape, bandaged with the 
cut surfaces in close apposition, and is thoroughly dried or baked. 

All wrinkles are then cut away from the inner surface, and 
extra padding is applied if necessary; the shirt is drawn tightly 
about the borders of the jacket and strips of leather provided 
with hooks are sewed in front so that it may be laced like an 
ordinary corset. It may be removed from time to time to allow 
for bathing, but it should always be removed and reapplied while 
the patient is suspended or in the recumbent position. 



96 OB THOPEDIC S UR GER Y 

The corset is sometimes used in place of the jacket during the 
active stage of the disease, but it is less effective, since the repeated 
stretching during removal and reapplication weakens the appli- 
ance and impairs the accuracy of adjustment. In addition, one 
of the strongest arguments in favor of the use of plaster of Paris, 
that treatment is under the control of the surgeon, is nullified. 

Comparison of the Two Forms of Ambulatory Support. — The 
most severe criticisms of the jacket have been made by those 
unfamiliar with its use, on theoretical grounds rather than from 
actual observation. While it may be admitted that there are 
certain objections to the support, yet experience has shown that 
when it is applied in a proper manner under proper conditions it 
is a thoroughly reliable, efficient, and often indispensable means 
of treatment. Indeed, it may be stated that by means of the 
jacket and the stretcher frame it is possible to treat nearly every 
case of Pott's disease without the aid of the professional brace- 
maker, and with success. 

It is evident, however, that under certain conditions the jacket 
must be inferior to the brace, in early childhood for example, 
when the pelvis is not sufficiently developed for proper support. 
Again, when the disease is low down, at or near the lumbosacral 
junction, the lower border of the jacket does not hold the pelvis 
with sufficient security to provide the proper fixation. In the 
upper dorsal region the attachments for accurate fixation may be 
adjusted more readily to the brace, and in disease of the cervical 
region the metallic head support is to be preferred to the halter 
of the jury-mast, for the reason that it cannot be removed by the 
patient. The traction of the jury-mast is very effective when 
properly used, and particularly so when painful distortion of the 
neck is present, but the tension on the straps is rarely constant, 
and thus loses in efficiency. A rigid support is, of course, prefer- 
able in the disease of the atloaxoid region. 

The jacket is most serviceable in the region from the tenth 
dorsal to the second lumbar vertebra. It is not only effective, 
but it is often a more comfortable support than the spinal brace. 
It is more efficient than the brace when lateral deviation of the 
spine is present; ajid from the clinical standpoint it is often more 
efficacious in relieving pain in this region when the disease is at 
all acute. One may conclude, then, that each form of support 
may be used according to the indications. The absolute control 
of the treatment, assured by the use of the plaster jacket, will 
often overbalance the claims of the brace. In practice among the 



TUBERCULOUS DISEASE OF THE SPINE 



97 



poor, when choice of means is not always permitted, it is indis- 
pensable; and it may be used with fair success even under con- 
ditions that theoretically contraindicate its employment. 

Modifications of the Jacket. — Occasionally, the form of the 
jacket may be changed to meet special indications; for example, 
backward traction may be secured by carrying the bandages over 
the shoulders; or the head may be fixed in the support, if the 
jury-mast is not at hand (Fig. 64); or one or both thighs may 




Plaster jacket, including the head to hold the spine in the extended position, 
as applied for disease of the upper dorsal region. 

be included in a spica jacket in painful disease of the lower region, 
when psoas spasm is present. Such modifications are required 
rather for emergencies than for continuous treatment. 

Corsets of Other Material than Plaster of Paris. — Corsets of 
wood, leather, paper, poroplastic felt, and celluloid are sometimes 
used. These are constructed on a plaster cast of the body, an 
accurately fitting jacket being used as a mould. 

? 



98 OB THOPEDIC S UR OER Y 

Such corsets have certain advantages of durability and elegance, 
but none of them has the accuracy of fit of the plaster-of-Paris 
corset, which is moulded directly on the body. Corsets of this class 
are usually somewhat expensive, and on that account are often worn 
after they are outgrown or when they no longer fit the patient. 
Their use is practically limited to the stage of recovery or for other 
affections than Pott's disease. 

Of these corsets, one of the best is that used by Weigel, of 
Rochester, made of alternate layers of linen cloth and wood-pulp 
matrix paper, fixed by a mixture of paste and glue. 

A more durable corset may be constructed of aluminum, as 
suggested by Phelps. This may be obtained in thin sheets, 
which may be hammered upon a metal cast of the trunk into the 
proper shape. The two halves are attached by hinges in the 
back and are perforated to permit ventilation. 

In the final stage of treatment, the Knight brace, a light steel 
frame with corset front, may be used (Fig. 68) or a long corset 
similar to that ordinarily worn by women, but strengthened by 
the insertion of light steel bars along the spine, may be sufficient. 

Other Forms of Support. — In certain cases of disease of the lower 
lumbar region it may advisable to restrain the movements of 
the thighs, although ordinarily, when this is necessary, ambulation 
should be discontinued. Such restraint may be attained by 
making the back bars of the brace stronger and extending them 
down the thighs to the knees like a double Thomas hip brace. 

If the jacket is used it may be extended to a single or double 
spica for the same purpose as has been mentioned. Such appli- 
ances are useful when psoas spasm and "cramp" are troublesome 
symptoms. 

In disease of the cervical region a certain amount of support 
and fixation may be obtained by collars of poroplastic felt, plaster 
of Paris, or other material. The Thomas collar (Fig. 65 and 66) 
is the best of this type of support, but none of them is thoroughly 
efficient unless used with a brace to control the larger movements 
of the spine. They are useful in emergencies, but they are not 
often required when proper braces can be obtained. 

Many other forms of apparatus of greater or less merit might 
be described, but space has permitted only a detailed account of 
three forms that, it would seem best, represent the essential prin- 
ciples involved in the treatment of Pott's disease. 

The Principles of Treatment in Their Practical Application. — After 
the description of the special forms of appliances used in the 



TUBERCULOUS DISEASE OF THE SPINE 



99 



routine treatment of Pott's disease, one may consider with ad- 
vantage the treatment in its more direct relation to the patient. 
The object of this treatment is to relieve the symptoms, to main- 
tain and to improve the vital resistance of the patient, to check, 
to remedy, and to prevent deformity. Under favorable con^ 
ditions the death-rate is small, and pain is easily relieved, but 
prevention of deformity is often extremely difficult. 

The effect of treatment must be estimated not simply by its 
relief of the symptoms of the disease, since deformity may steadily 
advance in spite of the apparent well-being of the patient, but it 
must be selected and continued or changed with the aim of com- 
bating ultimate deformity, and on this standard success or failure 
must be determined. It is probable that noticeable deformity 






The Thomas collar of leather stuffed with cotton. (Ridlon and Jones.) 
Fig. 66 




The Thomas collar for permanent use. A piece of thin sheet metal is cut wide 
enough to reach from the sternum to the chin, and from the back of the neck to the 
base of the occiput. The edges are turned out and the whole properly covered with 
felt and fitted. (Ridlon and Jones.) 

might be prevented, nearly always, if treatment were applied in 
season. But practically such opportunity is not often offered, 
and the local deformity that represents destruction of bone may 
be considered as irremediable. There is also a dwarfing and 
blighting effect of the disease, which, although it is usually asso- 
ciated with marked deformity, is always to be feared, particularly 
when the disease affects the middle or lower region of the spine 
in early childhood, and is severe and prolonged in its course. 
By proper treatment one may hope to check the progress of the 



LOFC. 



100 



ORTHOPEDIC SURGERY 



disease and even to remedy the deformity in great degree by free- 
ing the spine from the deforming influence of the local process 
and by preventing or removing the symptomatic distortions such 
as psoas contraction or wryneck. 

Indications for Treatment by Recumbency. — As has been stated 
already, the most important influence toward deformity when the 
spine has been weakened by disease is the force of gravity; there- 
fore, horizontal fixation in overextension is the most efficient 
means of preventing deformity, and of assuring the rest that 
favors repair. 




The Thomas collar applied. (Ridlon and Jones.) 



This is always the treatment for emergencies and in many 
instances the treatment of choice and routine. It is indicated as 
the routine treatment in infancy and in early childhood up to 
the age of three years at least. 

In many instances absolute recumbency may not be required, 
but the period of activity must be carefully regulated, and must 
be discontinued when there is evidence of discomfort or weakness 
or pain. If the period of activity must be short, it should be 
passed in the open air. The passive attitude of sitting, although 
less strain is thrown upon the spine than during activity, may be 
even worse for the patient; thus, the reclining or semi-reclining 



TUBERCULOUS DISEASE OF THE SPINE 



101 



posture should be assumed as a rule, when the child is in the 
house, at least during the active stage of the disease. Even if 
the spine appears to be perfectly supported, the time spent in 
bed should be long, and a period of rest in the middle of the day 
should be enforced. 

The arguments in favor of horizontal fixation in early child- 
hood do not apply to disease in the adult. At this stage the 
structure of the spine is resistant, and deformity is little to be 
feared, while such confinement would be irksome and impracti- 
cable; thus, local support, supervision, and, if possible, a change 



0k 

(i 


i 


V 


r 


f^BH 



The Knight brace with the back bars prolonged to support the head. 

of climate must be the treatment of selection for the adolescent 
or adult. 

In the middle period of childhood, from the fifth to the tenth 
year, horizontal fixation is the treatment for emergencies; for 
paralysis, for abscess, for dangerous disease of the atlo-axoid 
region, for progressive deformity, and for pain that cannot be 
relieved by the ordinary means. 

Special Indications for Treatment of Diseases of the Differ- 
ent Regions of the Spine. — In the selection of treatment, and 
in the general management of Pott's disease, each region of the 



102 



ORTHOPEDIC SURGERY 



spine must be judged by itself, since in each there are special 
difficulties to be met, and complications to be feared that may 
influence the prognosis and lead to modifications of the routine of 
treatment. 

The Lower Region. — The prognosis is good in disease of the 
lower region, the symptomatic attitude is favorable, the part may 
be supported easily, the cases are often seen early, and one 
may, as a rule, predict recovery without noticeable deformity, 
at most, but a slight shortening and broadening of the trunk 
and a peculiar erectness of attitude. Uncomplicated cases may 




Pott's disease of the middle dorsal region, a type <>{ disease in which horizontal 
fixation is always indicated. H. S., aged fourteen months. 

be treated with the brace or jacket. The brace is the better 
support when the disease is near the sacrum, while the jacket 
is often more comfortable and more effective than the brace 
when the middle or upper lumbar region is diseased, particu- 
larly when lateral deviation of the spine is present. Whenever 
the tendency to psoas contraction is at all marked or when pain 
or cramps in the limbs are complained of, the period of activity 
should be carefully restricted; in fact, the "night cry" is an in- 
dication for a day of rest in bed. 



TUBERCULOUS DISEASE OF THE SPINE 



103 



The most troublesome complications of this region are psoas 
contraction and the abscess with which it is often combined. 

As has been stated, psoas contraction changes the attitude 
of overerectness, favorable to repair, to a forward stoop that 
increases the pressure and friction at the seat of disease. If 
this attitude persists and if it becomes fixed by permanent changes, 
such as are likely to follow the burrowing of a pelvic abscess 
most disastrous deformity may follow; the body and the thighs 
are approximated and the erect attitude is made impossible. 
In neglected cases of this character, tenotomy and forcible cor- 
rection or even subtrochanteric osteotomy may be necessary to 




H. S., after fixation for fourteen months on the modified Bradford frame, 
shows the recession of deformity. Compare with Fig. 69. 

overcome the secondary deformity. In ordinary cases of psoas 
contraction, and when one limb only is flexed, the patient may 
be allowed to go about using a high shoe on the unaffected side, 
and crutches, so that the flexed leg need not affect the attitude. 
If, however, the contraction persists, it is well to place the patient 
on a frame, and to reduce the flexion by traction in the line of 
deformity, as will be described in the treatment of disease of the 
hip-joint. Persistent psoas contraction is almost always a symp- 
tom of abscess about the origin or in the substance of the muscle, 
and when it is accompanied by pain it is always an evidence of 
progressive disease. 
Abscess may be expected as a complication in at least 50 per 



104 



OR THOPEDIC SURGERY 



cent, of the cases of disease of this region, but it is by no means 
always accompanied by psoas contraction, any more than psoas 
contraction is always caused by abscess. Abscess unaccompanied 
by contraction more often has its origin above the lumbar region, 
and in its descent passes along the surface without involving the 
substance of the muscle. 




Final result of lumbar disease; spontaneous absorption of abscess, and but 
flight deformity. (See Fig. 13.) 

Attention is especially called to the fact that the bad results of 
Pott's disease of this region are caused almost invariably by 
allowing psoas contraction, whether it be symptomatic of abscess 
or not, to persist; therefore, the importance of preventing and 
correcting this deformity cannot be overestimated. It should be 
stated however, that in dispensary practice, when special care 



TUBERCULOUS DISEASE OF THE SPINE 105 

cannot be provided, one often sees psoas contraction that may 
have persisted for months relax, if the progress of the disease is 
favorable, without treatment other than the routine fixation of 
the spine by the brace or jacket (Fig. 72). 

The Lower Dorsal Region. — Disease of the lower dorsal region 
is very favorably situated for effective mechanical treatment, and 
psoas contraction and abscess are much less troublesome than in 
the lower part of the spine. 




The final result of extreme psoas contraction The direct bone deformity being 
comparatively slight. 

Deformity sometimes increases, almost imperceptibly, by a 
progressive forward bending or lordosis of the flexible lumbar 
spine below the projection. One must guard against this by 
applying the jacket firmly while the spine is made as straight as 
possible, or, if the brace is used, the lumbar spine should be 
drawn firmly against it. 



106 ORTHOPEDIC SURGERY 

If lateral inclination of the body is so marked as to interfere 
with the proper application of a brace, preliminary rest in bed is 
indicated. Lateral deviation can be corrected, as a rule, by the 
jacket without recumbency, although this, as other forms of symp- 
tomatic distortion, should be treated ordinarily, if not by com- 
plete rest, at least by careful regulation of the period of activity. 

Disease of the Middle and Upper Dorsal Region. — This is, from 
the standpoint of prevention of deformity, the most difficult 
region of the spine to treat, although the symptoms of the disease 
may be easily relieved. 

Deformity is present in nearly all cases when treatment is 
sought, and, deformity having begun, is very difficult to check, 
for the reasons that have been stated already. 

The final result in the majority of cases is what appears to be 
exaggerated round shoulders; the neck is shortened and projects 
forward, the chest is flat, and the shoulders are high. 

It is only by an early diagnosis and by efficient and long- 
continued treatment, beginning, if practicable, with horizontal 
fixation, that recovery from disease in this region without notice- 
able deformity may be hoped for. 

In all cases of disease above the ninth vertebra, the anterior 
brace for backward traction of the shoulders may be used with 
great advantage to secure greater fixation of the spine; and in all 
cases above the seventh or eighth vertebra a head or chin support 
to restrain the forward inclination of the neck is indicated in 
addition. 

With the plaster jacket the jury-mast or posterior support is 
employed; with the brace the looped chin rest or the ordinary 
Taylor support may be used. 

In disease of the upper dorsal region the brace is to be preferred 
to the jacket, because of the greater accuracy of adjustment, and 
because the halter of the jury-mast is rarely retained in proper 
position when the patient does not, as in these cases, feel the 
need of such support. 

In this region of the spine paralysis frequently occurs as a com- 
plication. When it appears after treatment is begun, it is usually 
a result of inefficient fixation of the spine or of want of caution in 
regulating the strain to which the diseased part is subjected. 
Its symptoms and its treatment will be considered later. 

Disease of the Upper Dorsal and Middle Cervical Region. — This 
is the most favorable region of the spine for treatment. The 
disease is usually not extensive because of the small size and coin- 



TUBERCULOUS DISEASE OF THE SPINE 107 

pact structure of the vertebrae; and the mobility of the cervical 
region is so great that it readily compensates for the local rigidity. 
Under efficient treatment one may predict recovery without 
noticeable deformity, and in the less successful cases the deform- 
ity is not, as a rule, offensive. The shoulders appear high, the 
neck is short, the head inclines forward, while the back is abnor- 
mally flat in compensation for the change in contour of the part 
above. 

When the case of cervical disease is first brought for treatment 
a wryneck deformity, often made more persistent by the infiltra- 
tion of an abscess or by enlarged cervical glands, is almost always 
present. As a means of correcting this distortion, the jury-mast 
and traction halter, attached to the jacket or brace, is a very 
efficient and comfortable support. Under the constant tension 
the deformity may be corrected with ease, but as a permanent 
treatment the brace and head support are to be preferred to the 
jury-mast, because a more exact fixation is assured. 

Disease of the Occipitoaxoid Region. — Under efficient treatment 
the prognosis is good, and recovery without deformity should be 
the rule. The course of the disease, although it is often accom- 
panied by acute symptoms, is usually short, as compared with 
that of other regions of the spine. It may be assumed that, in 
many cases, it is a primary arthritis, or, at least, that the primary 
focus in the atlas or axis is very small. The disease at this point 
is, however, in close proximity to the vital centres, and sudden 
death from displacement of the weakened parts is not uncommon. 
Abscess is frequent, and it is often a troublesome and dangerous 
complication. 

As has been mentioned, wryneck deformity is a very constant 
symptom, and there is also a strong tendency toward a forward 
and downward inclination of the head, so that in neglected cases 
the chin may rest upon the chest. The indications for treatment 
are to overcome the distortion and to hold the head fixed in the 
middle line, the chin being somewhat elevated above the right- 
angled relation with the spine. In the mild cases the jacket with 
jury-mast traction may be used to overcome the distortion, but 
the metallic head support with the fixation attachment to prevent 
motion in the diseased joints is always indicated as the treatment 
of selection, because by such apparatus the danger of displacement 
may be avoided. 

When the disease is acute in character, and especially if abscess 
is present, recumbency on the frame with fixation of the head and 



108 ORTHOPEDIC SURGERY 

slight traction by the weight and pulley, or by the jury-mast 
attachment, is indicated. This should not be sufficient to 
cause discomfort. Countertraction is supplied by the weight of 
the body and by elevation of the head of the bed or of the frame. 
The head sling may be that used with the jury-mast, or a simple 
band about the head may be used. Under this treatment 
slight deformity of any part of the cervical region will prac- 
tically disappear, and, as a rule, the course of the disease is very 
favorably influenced by the period of complete rest. In certain 
cases the attitude of recumbency is extremely uncomfortable. 
The discomfort is caused apparently by the forward projection of 
the upper part of the spine, so that when the head is drawn up- 
ward and backward in the recumbent attitude the calibre of the 
throat is lessened. In other instances the pain may be due to 
pressure of the atlas against the odontoid process of the axis. In 
such cases, if recumbency is desired, the head must be elevated 
by pillows to the point of comfort, the support being removed 
when the child has become accustomed to the position, or when 
the deformity has been corrected. 

The Complications of Pott's Disease. Abscess. — It may be 
assumed that a limited collection of tuberculous fluid is present 
at some time during the course of Pott's disease in the great 
majority of cases, but unless it appears as a palpable tumor above 
or below the thorax or upon the surface of the body its presence 
is not often detected. 

Townsend, 1 in 380 cases of Pott's disease examined with refer- 
ence to the occurrence of abscess as a complication, found that it 
was present or had been detected in 75 (19.7 per cent.); in 8 
per cent, of the eases of cervical disease; in 20 per cent, of the 
dorsal, and in 72 per cent, of those in which the lumbar region 
was involved. 

Dollinger, 2 in 700 cases under treatment from 1883 to 1895, 
found abscess in 154 (22 per cent.); in 13 of 63 cases in the cer- 
vical region (22.6 percent.); in 47 of 403 cases in the thoracic 
region (11.6 per cent.), and in 94 of 234 cases of lumbar disease 
(40.17 per cent). 

Ketch, 3 in 75 cured cases of Pott's disease treated at the New 
York Orthopedic Dispensary, selected for the purpose of con- 
trasting the behavior of the disease in the different regions of the 
spine, found that abscess had appeared in 19 (25.3 per cent.). 

1 Transactions American Orthopedic Association, vol. iv. p. 166. 

5 Loc. cit. 

8 Transactions American Orthopedic Association, vol. iv. p. 200. 



TUBERCULOUS DISEASE OF THE SPINE 109 

In the upper region abscess was detected in but 1 of the 25 cases 
(4 per cent.); in the middle region in 8 of the 25 cases (32 per 
cent.), and in the lower in 10 (40 per cent.). 

In 354 autopsies by Mohr, Nebel, Bouvier, and Lannelongue 
abscess was found in 281, or nearly 80 per cent. 

Although cases of Pott's disease that come to autopsy may be 
supposed to represent a severe type of disease, yet it is evident, 
by contrasting the statistics, that a large proportion of the ab- 
scesses escape detection in the living. One may conclude, then, 
that abscess may be expected as a more or less serious complica- 
tion in 25 per cent, of all cases of Pott's disease, and in at least 
half of those in which the lower region of the spine is affected. 
The greater frequency here is explained by the large size and 
less resistant structure of the vertebral bodies as compared with 
those of the upper regions. 

The tuberculous abscess is separated from the neighboring 
parts by a limiting wall varying in thickness according to its 
age, the outer layers of which are of fibrous and cellular tissue, 
the inner of granulation tissue covered with yellowish-gray or 
pinkish-gray necrotic membrane, which is easily separated from 
the underlying parts. The fluid of the abscess is usually of a 
whitish or whey-like color, composed of serum, leukocytes, and 
emulsified caseous material and fibrin. Floating in it are masses 
of cheesy necrotic tissue and sometimes minute fragments of bone, 
which settle to the bottom of the glass. Certain of the smaller 
quiescent abscesses contain only this whitish semisolid material. 
The fluid of abscesses in process of resolution is often clear, like 
serum; but if secondary infection has taken place the pus is of a 
greenish-yellow color, and is of uniform consistency. At any 
stage of its progress the abscess may become stationary and its 
contents may be absorbed; in fact, such an outcome is not un- 
usual. The fluid of the abscess is usually sterile, and secondary 
infection, before a communication with the exterior of the body 
is established, is comparatively uncommon. 

It has been claimed that abscess formation is always the result 
of infection with pyogenic germs, but this may be doubted, since 
the ordinary tuberculous abscess may be sterile or at most contain 
but a few tubercle bacilli. It is certain, on the other hand, that 
the formation and increase of the abscess is favored by irritation 
and injury, and that the most effective treatment of this compli- 
cation is to support the diseased spine and to relieve it from over- 
strain. 



110 OR THOPEDIC SURGERY 

Abscess is a symptom of disease, and it is in some degree an 
evidence of its character. If it appears early and increases in 
size rapidly it usually indicates a destructive and rapidly advanc- 
ing process, or infection from without. On the other hand, the 
slowly enlarging or quiescent abscess has but little significance. 
The abscess may cause no symptoms whatever, or it may be 
a source of inconvenience simply because of its size or situation. 
In many instances however, a period of malaise or discomfort 
or pain is followed and explained by the appearance of an abscess, 
but whether the symptoms are caused by the tension of the ab- 
scess or by a more acute phase of the disease itself is not always 
clear. 

Large abscesses that are increasing in size and approaching the 
surface are usually accompanied by pain and by elevation of tem- 
perature. This indicates, probably, a slight degree of secondary 
infection, but the ordinary deep abscess appears to have no other 
effect than to add, doubtless, to the susceptibility of the patient. 

The Course and Peculiarities of Abscess in the Different Regions 
of the Spine. — The tuberculous abscess may remain as a small 
collection of fluid in the neighborhood of the diseased area. As 
a rule, however, it slowly increases in size, and under the in- 
fluences of the force of gravity and the tension of its contents it 
finds its way down the spine or toward the exterior of the body, 
following the path of least resistance. The abscesses that have 
passed below the diaphragm or that have originated below this 
point may follow various paths. Some enter the sheath of the 
psoas muscle, and finally make their appearance on the inner 
aspect of the thigh, psoas abscess. Others perforate the sheath 
of the quadratus lumborum muscle and form a lumbar abscess, 
projecting between the twelfth rib and the crest of the ilium at 
the triangle of Petit. Those abscesses that escape from the fascia 
of the psoas muscle or that pass downward on the surface of the 
iliac fascia, the so-called iliac abscesses, may appear as a tumor 
over the outer extremity of Poupart's ligament at the junction of 
the transversalis and iliac fasciae, or the fluid may follow the 
course of the iliac artery to the thigh, or, escaping from the greater 
sacrosciatic foramen, form a gluteal abscess. The iliac or psoas 
abscess is most often confined to one side, but it may be bilateral, 
the two sacs communicating with one another by a larger or 
smaller channel. 

In the thoracic region the abscess may remain indefinitely in 
the posterior mediastinum, where, if large, its presence may be 



TUBERCULOUS DISEASE OF THE SPINE 



111 






demonstrated by an area of dulness extending toward the lateral 
region of the thorax, or it may perforate the intercostal muscles 
and appear on the posterior or lateral aspect of the chest, or it 
may pass downward through the aortic opening in the diaphragm 
and become an iliac abscess. 

Abscess caused by disease of the occipitoaxoid region may 
force its way forward between the recti muscles and appear be- 
hind the pharynx as the retropharyngeal abscess, or the fluid 
may take the opposite direction and distend the suboccipital 







Bilateral lumbar abscess. 

triangle and then pass forward to the region of the mastoid process. 
In other instances the abscess may dissect its way about the base 
of the skull or pass upward through the foramen magnum or 
downward into the spinal canal. 

Abscesses from the middle cervical region usually pass outward 
between the scaleni and longus colli muscles to the interval be- 
tween the trapezius and sternomastoid, perforating the skin about 
the middle of the lateral aspect of the neck near the anterior 
border of the latter muscle. 



112 ORTHOPEDIC SURGERY 

These are the paths usually followed by the tuberculous fluid, 
but occasionally it may enter the spinal canal or break into the 
pleural cavity or lung or intestine or by the side of the rectum or 
elsewhere. 

Treatment of Abscess. — Abscess is by far the most troublesome 
and dangerous complication of Pott's disease. It may interfere 
with proper mechanical treatment, and it is often a cause of per- 
manent as well as temporary deformity, especially in the lower 
region of the spine, as has been stated. It prolongs the course 
of the disease by extending its boundaries, and, although it is 
not often a direct cause of death, yet many patients die because 
of the exhaustion of long-continued suppuration that may follow 
secondary infection, and of the amyloid degeneration that may 
finally result. 

A large abscess is always a source of danger because of the 
possibility of secondary infection of its contents before it finds 
an outlet, and because of the probability of infection when a com- 
munication with the exterior has been established. Abscess is, 
however, a symptom and result of disease, and in properly treated 
cases it is, as a rule, a complication of comparatively slight con- 
sequence. If it is not present when treatment is begun, one may 
hope to prevent it by effective protection of the spine; and if it 
is present, this protection should be all the more rigidly enforced. 
An abscess often exists for months before its presence is detected, 
and after its discovery it may remain quiescent for a long time, 
and finally disappear. 

In a large proportion of cases the abscess causes no symp- 
toms, but slowly finds its way to the surface of the body. Mean- 
while it may be assumed that the disease of the spine, of which 
the abscess is a result, is in process of cure; so that when the 
fluid finds an outlet the source of supply will be shut off, and 
thus the patient is spared the danger and discomfort of discharg- 
ing sinuses, that so often persist after early operation. 

The so-called radical treatment of the abscess of spinal disease 
is unsatisfactory, not because it is different in character from 
other tuberculous abscesses, but because it is, as a rule, impossible 
to remove the disease of which the abscess is a symptom; and 
incomplete or ineffective surgical operations should be avoided. 

As the abscess is a symptom of disease, so, as a rule, its 
treatment should be symptomatic. The retropharyngeal abscess 
demands prompt evacuation, because it is likely to obstruct 
breathing and swallowing, because its sudden rupture may cause 



TUBERCULOUS DISEASE OF THE SPINE H3 

death, and because an abscess in such close proximity to the vital 
centres is always a source of danger. In cases of emergency the 
abscess may be evacuated by an incision in the middle line of the 
pharynx, but preferably the opening should be from the exterior. 
An incision is made along the posterior aspect of the sterno- 
mastoid muscle in its upper third. The abscess tumor is easily 
reached by careful dissection, and drainage is established which 
has evident advantages over that into the throat. 

Abscesses from the middle cervical region usually point in the 
lateral region of the neck and cause but little inconvenience. 
Abscesses in the upper thoracic region may, in rare instances, 
cause dangerous pressure on the trachea or lungs, as shown by 
spasmodic attacks of inspiratory dyspnoea, "asthmatic attacks." 
In some instances an area of dulness near the seat of disease 
demonstrates the position of the abscess, but if it lies in the 
median line it cannot be detected either by auscultation or per- 
cussion. If the inspiratory dyspnoea is well-marked the symptom 
may be fairly attributed to this cause, and if the spasmodic attacks 
are frequent and severe the operation of costotransversectomy is 
indicated. An incision is made, preferably on the right side, 
to expose the articulation between the transverse process and the 
rib, and one or two of these joints is resected; the finger is then 
inserted and passed along the surface of the adjacent vertebral 
body until the abscess sac is reached. This is usually directly in 
front of the spine at or about the fifth dorsal vertebra. After 
incision a large drainage tube should be inserted (Fig. 9). 

In the lower region of the spine intervention may be indicated 
because there is evidence of secondary infection. In this event if 
the abscess distends the lumbar region or forms a sac on either 
side of the spine, an opening in the loin on one or both sides of 
the spine is necessary. This is made as in operations on the 
kidney, by an incision on the outer side of the erector spinse 
muscle between the last rib and the crest of the ilium. In certain 
cases it is possible to expose the spine and to remove fragments 
of necrosed bone along with the contents of the abscess. As a 
rule, the complete removal of the lining membrane of the abscess 
is not practicable, and one must be content to evacuate the solid 
and semisolid contents by flushing with hot water, together 
with as much of the abscess membrane as may be removed by 
swabbing with gauze. The most important point in the oper- 
ation is to provide efficient and complete drainage of the cavity. 
Two or more counteropenings are usually necessary when the 

8 



114 ORTHOPEDIC SURGERY 

lumbarincision has been made, one just in front of the'anterior 
superior spine and another in the thigh, if the abscess is of the 
psoas variety. Long drainage tubes are inserted, and should 
remain until a proper channel for the escape of pus has been 
established. 

If the abscess is of one side only, not extending into the thigh, 
and if evacuation seems advisable because of its size or tension, 
it may be opened by an anterior incision below Poupart's ligament 
just to the inner side of the sartorius muscle. After expression 
of its contents a drainage tube may be inserted long enough 
to reach to the seat of disease if it be of the lumbar region. 

The dressing should be of dry sterile gauze, and great attention 
should be paid to absolute cleanliness and to effective drainage. 
As soon as it is possible, if the discharge has become slight and 
if the spine can be properly supported, the patient is allowed to 
walk about and to go into the open air. In ordinary cases a slight 
discharge persists for several months or longer, depending on the 
condition of the disease. 

In the symptomatic treatment of abscess, aspiration is some- 
times of service, for by this means it may be prevented from 
increasing in size; and if the disease is quiescent, the cure of the 
abscess may follow the removal of its contents which allows the 
collapse of its walls. When aspiration is employed it should be 
repeated systematically as often as the abscess cavity refills. 
After each evacuation pressure should be applied to favor the 
adhesion of the apposed walls. 

If the contents are of such a nature that aspiration is ineffec- 
tive an incision may be made, through which the semisolid sub- 
stance may be removed. The opening is then closed by several 
layers of sutures, and pressure is applied with the aim of ob- 
taining primary union. This operation may be repeated several 
times if necessary. Often a sinus eventually forms at one or other 
of the openings. 

Until recently the injection of antituberculous remedies into the 
abscess sac was in favor. This is probably of value in dimin- 
ishing the infective quality of the contents, perhaps, also, in 
lessening the danger of mixed infection and in stimulating the 
reparative processes. Clinically, it appears to have little direct 
effect upon the course of the tuberculous disease. An emulsion 
of iodoform in sterilized oil or glycerin (10 to 20 per cent.), in 
doses of from 4 to 30 grams, is injected at intervals of from 
two to four weeks, with or without previous evacuation of the 



TUBERCULOUS DISEASE OF THE SPINE H5 

contents; the amount and the frequency of the injection depend- 
ing upon the age of the patient and upon the effect of the treat- 
ment. If used with caution as to asepsis, and to the toleration of 
the patient for iodoform, no harm will follow, even if the treat- 
ment proves to be of little practical value. 

When an abscess approaches the surface the skin becomes red 
and thin, and there is usually some local sensitiveness and pain. 
Whenever spontaneous evacuation of the abscess is probable the 
mother should be instructed as to the necessity of absolute clean- 
liness, and the proper dressings should be provided. In such an 
event the patient should remain in bed for several days, or until 
the discharge has become small in amount. 

In the symptomatic treatment of the abscesses of Pott's disease 
one may conclude, then, that operation will be indicated in the 
treatment of the retropharyngeal abscess and in the rare instances 
when dangerous pressure is exerted by an abscess in the posterior 
mediastinum. It is indicated, of course, when there is evidence 
of mixed infection or when the rapidly enlarging abscess causes 
discomfort or interferes with effective support. It is usually 
indicated when the abscess is of large size if proper care can be 
provided. The operative treatment is practically free from 
danger if cleanliness and efficient drainage can be assured. As- 
piration is free from danger; it is often of service in preventing 
the enlargement of the abscess, and it may hasten its absorp- 
tion. An incision which allows for the evacuation of the solid 
material, followed by immediate closure of the wound, is in many 
instances the operation of selection. 



Paralysis. " Pott's Paraplegia." 

The tuberculous process in the vertebral bodies may extend 
backward, and breaking through the posterior ligament it may 
enter the epidural space and press upon the spinal cord; then 
follows paresis or paralysis of the parts below the constriction. 

The calibre of the spinal canal is not usually lessened by the 
characteristic angular distortion of the spine, although the weight 
and forward inclination of the trunk may force the softened 
tissues backward against the cord and thus increase the direct 
pressure; in fact, paralysis is much more often associated with 
a slight or moderate kyphosis than with extreme deformity. 

In rare instances the pressure may be due to a fragment of 



116 ORTHOPEDIC SURGERY 

necrosed bone or to solidification of the tissues in and about the 
canal during the process of repair. It may be caused, in part, 
at least, by the pressure of a neighboring abscess, but it is usually 
the result of the slow advance of the tuberculous disease. When 
this has forced an entrance into the spinal canal it sets up a 
resistant inflammatory thickening of the coverings of the cord, 
— first a peripachymeningitis and then a pachymeningitis. In 
addition to the direct pressure, there may be an interference 
with blood supply and the lymphatic circulation, with result- 
ing local oedema of the cord. An increase in the interstitial 
connective tissue of its substance and a corresponding atrophy 
of the nervous elements may follow, and as a sequence an ascend- 
ing and descending degeneration that, in prolonged cases, may 
terminate in partial or complete sclerosis. The dura mater is 
a resistant structure, and direct destruction of the cord by the 
tuberculous disease is rare. In fact, as a rule, but little per- 
manent damage results, even from long-continued pressure and 
paralysis, for the cord seems in these cases to possess the power 
of repair and regeneration to a remarkable degree. 

Frequency. — In 1670 cases of Pott's disease recorded at the 
New York Orthopedic Dispensary, paralysis occurred in 218, ' and 
in 445 cases in the private practice of Dr. C. F. Taylor, 2 59 cases 
of paralysis were observed. Thus, in a total of 2015 cases of 
Pott's disease there were 279 cases of paralysis, or 13.7 per cent. 

This proportion is much larger than the normal, however, for 
many of the patients were taken to the specialist or to the special 
hospital because of the paralysis, as in 40 of Taylor's and in 133 
of the dispensary cases. If these be excluded, the percentage of 
paralysis occurring in those actually under treatment is reduced 
to 5.6 per cent. This percentage corresponds very closely to 
that of Dollinger, 3 viz., 41 cases of paralysis in 700 cases of Pott's 
disease under treatment (5.8 per cent.), and it may be accepted 
as representing the average liability to paralysis among those 
who have received treatment for Pott's disease, the percentage 
being much higher in neglected cases. 

The Liability to Paralysis in Disease of the Different Regions of 
the Spine. — The liability to paralysis is very much greater in 
disease of certain regions of the spine than in others. 

Thus, 105 of the 209 cases in Myers' list, in which the situa- 

1 Myers, Transactions American Orthopedic Association, 1891, vol. iii. p. 209. 

2 Taylor and Lovett, New York Medical Record, June 19, 1896. 
8 Loc. cit. 



TUBERCULOUS DISEASE OF THE SPINE H7 

tion of the disease was recorded, complicated disease of the dorsal 
region above the eighth vertebra. Of the remainder, in 16 the 
disease was of the cervical region; in 12 of the cervicodorsal, and 
in 59 of the lower dorsal and dorsolumbar regions. 

Thirty-seven of Taylor's 59 cases were caused by disease of the 
dorsal region; 8 occurred in the cervical and cervicodorsal and 
11 in the dorsolumbar and lumbar regions. 

Twenty-six of the total of 41 cases recorded by Dollinger were 
caused by disease of the third to the seventh dorsal vertebrae, 
inclusive, or about 23 per cent, of the cases in which this region 
was involved. 

Of 132 cases of paraplegia reported by Gibney 1 not one com- 
plicated lumbar disease; nearly all were caused by compression 
in the middle or upper thoracic region. 

These statistics show that the upper and middle dorsal section 
is the point of greatest liability to paralysis — a fact that is ex- 
plained possibly by the smaller size of the canal at this point, 
and by the difficulty in assuring complete fixation at the seat of 
disease. It may be estimated that in 15 per cent, of the cases 
of Pott's disease of this region paralysis will appear before cure 
is established. 

Time of Onset. — In exceptional cases the paralysis may pre- 
cede deformity, and it may be the first symptom that attracts 
attention to the disease. In 14 of 74 cases reported by Gibney 
the paralysis was present when the bone disease was recognized, 
but it is probable that the primary disease had existed for several 
months before the appearance of the paralysis. Usually it is 
a comparatively late symptom, appearing after the stage of 
deformity and more often six to twelve months after the recogni- 
tion of the disease, but its appearance may be deferred until 
long after apparent cure. 

Duration. — In exceptional cases the paralysis appears to be 
caused simply by disturbance of the circulation of the cord, due 
possibly to the pressure of the superincumbent weight upon the 
softened and diseased tissues, as it disappears almost immediately 
when the spine is straightened and supported. Usually the 
paralysis persists for several months, not infrequently it lasts a 
year, and partial or even complete recovery is possible after a 
much longer time. Recovery from the paralysis depends upon 
the course of the disease of which it is a symptom, upon the ab- 

1 Journal of Nervous and Mental Disease, January 5, 1897. 



118 ORTHOPEDIC SURGERY 

sorption and organization of the tuberculous granulations that 
press upon the cord, and upon the regenerative changes in its 
structure, if it has been implicated in the disease. 

Symptoms of Pott's Paraplegia. — The most marked effect of 
the pressure on the cord is the interference with its conductivity. 
The reflex centres situated below the point of constriction, re- 
lieved from the inhibition of the brain, become overactive, while 
voluntary motion of the parts below the constriction is difficult 
or impossible. The pressure of the diseased products is more 
directly upon the anterolateral columns, so that motion is much 
more often primarily affected than is sensation. 

The early symptoms of Pott's paraplegia, as noticed by the 
patient or his friends, are weakness, awkwardness, and a stum- 
bling, shambling gait. The symptoms usually increase rapidly 



Pott's paraplegia before the stage of deformity. The apparatus used in the 
treatment of this case is shown in Fig. 54 

until paralysis of motion is complete. At this stage the patella 
tendon reflex is increased, and ankle-clonus is often present. As 
a rule, both limbs are affected in equal degree, but occasionally 
paralysis of one may be more complete or may precede that of the 
other, and in the stage of recovery power may return more rapidly 
on one side than on the other. The limbs in the early stage of the 
paralysis may appear limp and powerless, but when the patient 
is moved or when the reflexes are stimulated the peculiar spastic 
rigidity or stiffness appears. 

As a rule, the stiffness increases with the duration of the dis- 
ease, and spastic contractions are often present; thus, the thighs 
may be approximated, the knees flexed, and the feet extended. 
Persistent contractions indicate, as a rule, permanent damage to 
the cord, and in such cases complete recovery is unusual. 



TUBERCULOUS DISEASE OF THE SPINE H9 

Sensation is not affected ordinarily, but in the more severe or 
prolonged cases it may be impaired or lost. Sensation was re- 
tained throughout in 24 of the 40 cases reported by Shaffer. 

In the cases of partial paralysis control of the bladder may be 
retained, but usually there is incontinence. As the bladder fills 
the reflex centre is excited, and it empties itself. 

The control of the sphincter ani is less often or less noticeably 
affected. 

As the paralysis is the result in many instances of active or of 
advancing disease its onset may be preceded by discomfort or 
pain. Thus, noticeable discomfort attended by an exaggeration 
of the patella tendon reflex may be considered as an indication 
for enforced rest of the individual, although increased activity of 
the reflexes is rot uncommon during the progressive stage of the 
disease without apparent involvement of the spinal cord. When 
paralysis occurs in patients who are under treatment for Pott's 
disease the onset is not attended, as a rule, by noticeable or un- 
usual pain; nor is pain usually complained of after the paralysis 
has developed. 

The extent of the paralysis depends upon the situation of the 
disease. In exceptional cases, in which the cervical cord is im- 
plicated, both the arms and legs may be paralyzed; this 
occurred in seven of the cases reported by Myers. As a rule, how- 
ever, the paralysis is a complication of disease of the dorsal region 
above the reflex centres in the lumbar enlargement of the cord 
but below the nerve supply of the upper extremities. If the 
disease is at a lower point, for example, in the dorsolumbar section 
so that these reflex centres themselves are directly implicated, 
reflex activity is not increased, and intermittent incontinence 
is replaced by constant dribbling of urine. If the cauda equina 
alone is implicated in disease of the lumbosacral region the 
symptoms are those of neuritis, pain, numbness, and weakness 
in the area supplied by the affected nerves. Such weakness 
with accompanying muscular atrophy may be present in the upper 
extremities when the disease is in the neighborhood of the origin 
of the brachial plexus, while in the lower limbs the characteristic 
spastic condition is evident. 

In characteristic cases the nutrition of the limbs is not, as a 
rule, greatly affected, nor do the contractions become permanent; 
but when the paralysis is prolonged, and when sensation is lost, 
the muscles waste, the circulation is impaired, and fixed distor- 
tions usually appear. Even in the more prolonged and severe 



120 ORTHOPEDIC SURGERY 

forms of paralysis, occurring in childhood, bed-sores are rarely 
seen. 

Prognosis. — In properly treated cases the prognosis is very 
favorable, as is illustrated by the final results of 47 of the 59 cases 
of paraplegia in Taylor's practice. Of these 39 recovered com- 
pletely, 5 died of intercurrent disease while apparently recov- 
ering, and in 3 the recovery was partial. 

Of the hospital cases recorded by Myers, 3 per cent, died of 
intercurrent disease. The final results could be ascertained in 
but 55 per cent, of the patients who remained under treatment. 
All of these recovered. 

Of 74 cases of paraplegia treated by Gibney, 1 45 were cured, 
12 improved, 8 unimproved, and 9 died. Thus, 77 per cent, were 
cured or improved. In a similar series of 40 cases reported by 
Shaffer, 80 per cent, were cured and but 10 per cent, of the 
remainder were considered as hopeless cases. 

In a total of 975 cases "abandoned to medical treatment," 
collected from various sources by Rozoy, 2 there were 429 cures. 
Of the remainder 16 were improved, 130 were unimproved, and 
there were 244 deaths. The contrast in the results reported would 
appear to show the advantage of thorough mechanical treat- 
ment. 

Recurrence of paralysis after recovery is not infrequent; in 
18 cases such recurrences from one to four times are recorded by 
Myers, and seven successive attacks of paralysis were observed 
in a patient under treatment at the Hospital for Ruptured and 
Crippled. 

The relapses are due apparently to the renewed activity of 
the disease, and in many instances this may be explained by the 
neglect of protective treatment. 

Treatment. — The treatment of the paralysis is included in the 
treatment of the disease of which it is a symptom, except that even 
greater care should be exercised to assure fixation of the spine. 

Rest in the position of hyperextension on the stretcher frame 
is indicated. Direct traction by the weight and pulley should 
be used if the disease is in the upper dorsal or cervical regions. 
For bedridden patients a convenient method of assuring extension 
of the spine in connection with head traction is to suspend the 
trunk on a sling of canvas drawn transversely beneath the seat 
of disease and attached to bars on the sides of the bed after the 

1 Loc. cit. 2 Mai. tie Pott. Paris, 1901. 



TUBERCULOUS DISEASE OF THE SPINE ]21 

Rauchfuss method. The back brace or the plaster jacket assures 
additional fixation, and such support should be employed when- 
ever practicable. If, however, the brace has been worn as an 
ambulatory support, its shape must be modified to accommodate 
the change in the outline of the spine, induced by recumbency 
and extension. 

Manipulation or massage of the limbs is contraindicated because 
it stimulates the reflex centres. If persistent contractions of the 
muscles are present the deformity may be reduced by traction 
applied in the ordinary manner (Fig. 33), or a fixation brace may 
be worn. The spasmodic contractions are often painful, and if 
the paralysis is complicated by tuberculous joint disease, traction 
and fixation may be indicated to relieve the joint from the in- 
jury of involuntary motion. 

Counterirritation at the seat of disease was by Pott considered 
of the greatest value, and the application of the actual cautery 
from time to time, about the kyphosis, seems in certain cases to 
exert a favorable influence on the underlying disease. 

Electricity, particularly galvanism, has been used, and it is of 
some service in preserving the nutrition of the limbs. Its value 
in a case must be judged by its effect. 

Internal remedies are of little value with the possible exception of 
iodide of potassium, which is supposed to act upon the tubercu- 
lous granulation tissue as upon the products of syphilitic disease. 
A convenient method of administration is a solution of which one 
drop represents one grain of the drug. This is given in milk or 
in Vichy water, beginning with five drops three times daily and 
increasing the dose a drop each day until the point of toleration 
is reached. 

The first indication of improvement is usually lessening of the 
muscular rigidity; then the ability to move a toe may be regained, 
after which recovery follows quickly. At this stage massage of 
the limbs may be employed with advantage. The exaggerated 
reflexes may persist long after recovery; in fact, as has been stated 
this symptom is not uncommon among patients suffering from 
dorsal Pott's disease who have never been paralyzed. 

The Operative Treatment. — The operation of laminectomy was at 
one time in favor, but it has now been practically abandoned, as 
a treatment of routine at least, for the paraplegia of Pott's disease, 
because it has been proved that recovery, if somewhat long de- 
ferred, is the rule without operation, while the direct death-rate 
of the operation is large. 



122 ORTHOPEDIC SURGERY 

In 134 cases collected by Rhein 1 the immediate mortality (those 
dying within a month after the operation) was 36 per cent. 

Lloyd 2 has collected 128 "reliable" cases of Pott's disease in 
which laminectomy was performed. The deaths due directly to 
the operation were 21 (16.45 per cent.); subsequent deaths, 36 
(28.20 per cent.); total deaths, 57 (44.55 per cent.); recoveries, 
37 (28 per cent.); improved, 16 (12.5 per cent.); unimproved, 
18 (14.06 per cent.). Of eight cases operated by Trendelenburg 
in 1889 six were living and well in 1905. One was unimproved. 3 

Laminectomy is an incomplete operation in the sense that the 
disease of the bone is not removed, thus recurrence of paralysis 
from extension of the disease is not infrequent after a successful 
immediate result. It should be reserved for those cases in which 
after a thorough and prolonged trial of ordinary methods the con- 
dition does not improve. Eighteen months has been suggested 
as the proper time in which to test conservative treatment. The 
operation may be indicated also if the symptoms, in spite of treat- 
ment, increase in severity, particularly when the cervical region 
is involved or when there is evidence that the integrity of the 
cord is threatened, or when the paralysis is of sudden onset, or 
when displacement of bone or pressure from an abscess seems 
probable as the exciting cause, although in the latter instance 
the direct evacuation of the abscess by costotransversectomy, as 
advocated by Me'nard, should precede laminectomy. Occasion- 
ally, the operation is indicated as a forlorn hope in adults suffer- 
ing from cystitis and bed-sores. 

The usual method in operating is as follows: 4 A long incision 
is made parallel to and close by the side of the spinous processes. 
The muscles are drawn to one side, the spinous processes are cut 
through and drawn with the attached muscles to the opposite 
side. The lamina? at the seat of disease are then removed with 
the cutting forceps exposing the dura mater. The tuberculous 
tissue is usually found upon the front or lateral surfaces of the 
canal, and its complete removal is often impossible. The shock 
of the operation is often marked, so that it should be as rapid as 
possible, and loss of blood should be carefully guarded against. 

1 Willard, Journal of Nervous and Mental Disease, May, 1897. 

2 Philadelphia Medical Journal, February 22, 1902. 

3 Sultan, Zeitsch. f. Chir. v. lxxviii., 1 and 2. 

4 It should be borne in mind that the segments of the cord do not correspond to the 
spinous processes of the same number. Thus, in the cervical region the affected seg- 
ment is one vertebra higher. In the upper dorsal region two higher. From the sixth 
to eleventh dorsal three higher. The three lower lumbar and sacral segments are. to be 
found opposite the eleventh afld twelfth dorsal spines. (Chipault.) 



TUBERCULOUS DISEASE OF THE SPINE 123 

As a rule, the wound may be closed without drainage. After the 
operation the spine should be supported by the brace or jacket 
until the disease is cured. 

In several instances forcible correction of the spine (Calot's 
operation) relieved the pressure on the cord and rapid recovery 
followed. This indicates the importance of assuring overexten- 
sion of the spine whenever it is possible, but this should be 
attained preferably by gradual, postural correction rather than 
by force. 

Fortunately, the great majority of cases of paraplegia from 
Pott's disease occur in childhood, and, as has been mentioned, 
the complications of later life, bed-sores, cystitis, and the like, are 
rarely troublesome. Such paralysis in the adult is more serious 
from every point of view. The principles of treatment are the 
same, but their application is more difficult and the prognosis is 
more doubtful. 

Local Paralysis. — In certain cases the extension of the disease 
may involve the nerve roots at their exit from the spine. This 
may occur with or independently of the involvement of the cord. 
The symptoms are those of neuritis in the affected nerves. In 
extremely rare instances the pressure on the cord may cause 
hemiplegia. 

Forcible Correction of the Deformity of Pott's Disease. 
Calot's Operation. — Forcible correction of the deformities of 
the spine was advocated by several of the ancient writers, notably 
by Hippocrates and by Pare. 

In 1896 the method which had been revived by Chipault sev- 
eral years before 1 was popularized by Calot, of Berck sur Mer, 2 
who claimed that it was particularly adapted to the treatment of 
the kyphosis of tuberculous disease. 

In brief, the operation consisted in forcibly straightening the 
spine by horizontal traction and by direct pressure on the 
deformity. Afterward the patient was fixed in the proper atti- 
tude by a plaster appliance for several months. After an extended 
trial the procedure has again been abandoned and the detailed 
description to be found in the former editions has been omitted 
in the present volume. 

The Duration of the Treatment of Pott's Disease. — The dura- 
tion of the treatment must depend upon the extent and severity 
of the disease. It may be divided into two periods: one during 

1 Travaux de neurologie Chir., 1895, 1896, 1897. 
J Archiv. prov. de Chir., February, 1897, t. 6, n. 2. 



124 ORTHOPEDIC SURGERY 

which the disease is active, when fixation is indicated, and 
a stage of recovery, during which supervision is required. 
During the first stage the destructive process may increase the 
direct deformity; during the later period of weakness the dis- 
tortion may increase, simply because of the general inclination 
toward deformity and because of the atrophy of the supporting 
muscles. 

Tuberculosis of the spine is slow in its progress, and recovery 
is often insecure. The course of the disease is shortest in the 
cervical region, but even here two years of brace treatment will 
probably be required, and in the lower region double this time 
even in the milder type of cases. Active treatment should be 
continued as long as there is evidence of disease. The absence 
of actual pain and discomfort is of little value in determining the 
absolute cure if braces have been employed. The absence of 
muscular spasm is more significant, since it usually persists as 
long as the disease is active. The presence of pain on passive 
motion or muscular contraction or abscess would, of course, indi- 
cate the necessity of further treatment. 

Direct palpation is of some value in determining the condition 
of the affected part. During the progressive stage, careful, deep 
pressure over the spinous processes may show greater mobility of 
those involved in the disease. During the stage of repair and 
consolidation the mobility is replaced by rigidity. The appear- 
ance of the kyphosis has some significance. In the early stage of 
the disease its area is not clearly defined, but when consolidation 
has taken place its extent is shown by the rigid vertebrae, which 
stand out separated from the remainder of the spine by a well- 
marked sulcus, which is much deeper below than above the 
kyphosis. 

Even when the disease appears to be cured, removal of support 
should be gradual and tentative; the jacket should be replaced 
by the corset, or the brace by a lighter appliance ; then support 
may be removed at night, later for part of the day, and at last, 
after many months, it may be discarded. Then may follow 
massage of the atrophied muscles of the trunk and gentle exercise. 

Such careful supervision must be continued for a much longer 
time if the best ultimate result is to be attained, for, as has been 
mentioned, one should guard against the secondary distortions, 
which may be due simply to weakness and to the unfavorable 
mechanical conditions induced by the primary deformity. If 
curvatures of the spine are so common among normal individuals 



TUBERCULOUS DISEASE OF THE SPINE 125 

how much^more likely is deformity to increase when the trunk 
has been weakened by disease and by long disuse of the muscles. 

This secondary increase of deformity is not so much to be 
feared after the cure of the disease in the lumbar region, because 
of the favorable attitude of erectness, nor is it likely to be marked 
after cure in the cervical region of the spine; but in disease of 
the upper and middle dorsal region support must be continued 
long after recovery, and supervision must be exercised until after 
the period of adolescence, if increase of the deformity is to be 
prevented. 

Recurrence of Disease and Later Effects of Deformity.— The 
disease may recur after an interval of many years of apparent 
cure, and such recurrences are often accompanied by the 
formation of an abscess or by paralysis. 

If recovery from Pott's disease has been complete, and if de- 
formity has been prevented, the condition of the patient is to all 
intents normal; but if the course of the disease has been prolonged, 
and if the deformity is great, his condition is abnormal. He is 
unfitted for ordinary occupations, and comparative comfort is 
assured only by constant care. Such individuals are likely to 
suffer from neuralgic pain about the weakened spine on over- 
exertion or whenever the general condition is depressed from any 
cause. In such cases the use of some form of light corset adds 
to the comfort of the patient. 

In certain instances pain localized in the lateral region of the 
trunk may be caused by compression of an intercostal nerve, or 
it may be due to compression of the tissues between the last rib 
and the pelvis. In several cases of this character reported by 
Goldthwait, resection of a portion of a rib at the seat of pain 
relieved the discomfort. 

Secondary Deformities. — While the patient is under treatment 
for Pott's disease one should be on the alert to prevent other 
deformities that may follow the general weakness and restriction 
of normal functions. One of these is the weak foot, sometimes 
called weak ankle or flat-foot, and with it is often associated a 
moderate degree of knock-knee. This may be prevented by a 
shoe of proper shape, of which the heel and sole are thickened 
slightly on the inner side. 



CHAPTER II 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE. 



Syphilis. 

Syphilis, in thejnherited or]jin the later stages of the acquired 
form, may affect the bones of the spine and cause local deformity 
and symptoms that cannot be distinguished from those of Pott's 
disease. 

Diagnosis. — As compared with tuberculosis it is a rare disease 
of the spine. 1 Its manifestations are likely to be general in char- 
acter, the deformity of the spine 
being but one of many evidences of 
disease. 

If syphilis were limited to the 
spine and simulated the symptoms 
and the deformity of Pott's disease 
it would demand the same local 
treatment. Specific remedies should 
be administered when one has reason 
to suspect the presence of the syph- 
ilitic taint, even if the local disease 
appears to be tuberculous in charac- 
ter. 

4 - Malignant Disease of the Spine. 



Malignant disease of the spine is 
a rare affection, particularly so in 
childhood. Sarcoma is more com- 
mon than carcinoma, and it may 
affect the spine primarily. Carci- 
noma is almost always secondary to 
a primary tumor elsewhere, the spine 
becoming involved by metastasis or 
in 3720 cases of carcinoma found 




Vertical anteroposterior section of 
the lumbar spine, showing deposit of 
gumma in the posterior part of the 
third and fourth vertebra. (After 
Fournier.) 

by contiguity. Schlesinger 2 
secondary growths in the spine in 54. 



1 Jasinski, Archiv f. Dermat. u. Syph., Bd. xxiii., S. 400. 

1 Buckley, Journal of Nervous and Mental Disease, April, 1902. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 127 

Diagnosis. — Malignant disease differs from tuberculosis of the 
spine in that its symptoms are usually more severe; the pain is 
usually persistent, and it is not relieved by support or recum- 
bency, as is that of Pott's disease. The constitutional symptoms 
are more marked and the steady progress of the disease toward 
a fatal termination is soon apparent. Locally, the angular de- 
formity is usually slight, and it may be absent. Not infrequently 
the tumor may be palpated through the abdominal wall. 

Paralysis is a frequent and often an early symptom. In a 
case of melanotic sarcoma of the spine in a boy aged twelve years, 
complete paralysis of motion and sensation in the lower extremities 
preceded noticeable symptoms pointing to the local disease. 

As has been stated, carcinoma is almost always secondary to 
disease elsewhere; thus, if after the operation for the removal of 
carcinoma symptoms of disease of the spine appear one should 
suspect this complication. 

Malignant disease of the spine is a fatal affection, and the 
treatment can be but palliative. 



Acute Osteomyelitis of the Spine. 

Infectious osteomyelitis of the spine is comparatively uncommon. 

Symptoms. — The symptoms are similar to those of acute infec- 
tious processes elsewhere, and are characterized by sudden onset, 
with pain, fever, and constitutional depression. There are local 
pain and tenderness about the spine and in many instances 
distention of the veins in the neighborhood caused by interfer- 
ence with the circulation by septic thrombosis. Abscess quickly 
forms, and paralysis from the rapid extension of the disease is 
a common complication. 3 The symptoms due to pyogenic in-, 
fection and to deep-seated abscess are often pyaemic in character 
and necrosis of the affected vertebral bodies may result in the 
formation of large sequestra. 

In sixty-one cases collected from literature by Hunt, 1 the 
situation of the disease was as follows : 

Cervical region 12 

Thoracic region 15 

Lumbar region 24 

Sacral region 10 

Either the bodies or the arches of the vertebrae may be primarily 
involved. 

1 Medical Record, April 23, 1904. 



128 OB THOPEDIC S UB GEB Y 

The cause of the infection in fifteen of the twenty cases examined 
was the Staphylococcus aureus. 

According to Grisel, 1 in forty of fifty-six cases reported, the 
patient died of general infection, pleuropneumonia, or meningitis 
before the diagnosis was made and before abscess had appeared. 
The mortality was about 56 per cent. 

Recovered. Died. 

Suboccipital region 1 4 

Cervical 2 2 

Dorsal 7 3 

Lumbar 13 15 

Sacral 6 

23 30 

A more localized and more chronic, and of course far less dan- 
gerous, form of osteomyelitis may occur, and abscess may be the 
first sign of the disease. In all cases of this character, whether 
acute or chronic, other bones or joints or other tissues are often 
involved, and in many instances an infected wound or discharging 
ear, for example, may indicate the source of infection. 

Treatment. — The treatment consists in the immediate evacua- 
tion and drainage of the abscess, the removal of the necrosed 
bone if possible, and in supporting the spine during the subse- 
quent stage of weakness. 



Actinomycosis of the Spine. 

Actinomycosis of this region is extremely uncommon, the 
spine having been involved secondarily in about 2 per cent, 
of the reported cases. 2 The diagnosis may be made by the 
microscopic examination of the discharge from the sinuses that 
almost always form when bone is affected. 



Injury of the Spine. 

Severe sprains or fractures may simulate disease very closely, 
and in some instances, particularly of injury of the cervical region, 
the diagnosis is practically impossible until after treatment by 
support and fixation has been applied, when, as a rule, if disease 
be absent, the symptoms, even though of long standing, quickly 
subside. 

1 Revue d'orthop&lie, September, 1903. 

a Erving, Johns Hopkins Bulletin, November, 1902. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 129 

Fracture of the spine in the middle region may result in angu- 
lar deformity, and when proper support has been neglected, 
symptoms of pain and weakness, similar to those of Pott's disease, 
may persist indefinitely. 

Sudden forcible compression of one or more of the vertebral 
bodies without displacement and without severe immediate symp- 
toms, other than the slight deformity, may be the result of injury, 
especially falls from a height. These cases are not uncommon, 
and as the severity of the injury is not often recognized, the local 
deformity, which may not attract attention until several weeks 
after the accident, combined with stiffness and weakness, lead to 
the mistaken diagnosis of Pott's disease. 

Rupture of spinal ligaments may be caused by forced forward 
bending of the spine. The resulting deformity and weakness re- 
semble the symptoms caused by a crush of one of the vertebral 
bodies. A number of cases have been described by Painter and 



Traumatic Spondylitis. — Kummell 2 has described a form of 
rarefying ostitis of the spine of non-tuberculous origin, appar- 
ently caused by injury. It is characterized by symptoms of pain 
and weakness referred to the back, and by a pronounced rounded 
kyphosis of the dorsal region. Motor disturbances of the lower 
extremities are frequent. This is easily explained by the fact 
that in cases of this character fracture, disorganization of the 
disks, rupture of ligaments, hemorrhage beneath the longitudinal 
ligament, into the muscles or into the spinal canal, have been dem- 
onstrated at autopsy. Indirect injury, shock to the nervous appa- 
ratus and the like may cause complicating symptoms in addition. 3 

Kummell's cases do not differ particularly from those of injury 
that have been described. In fact, in the neglected cases of 
injury of the spine the pain and weakness may persist indefi- 
nitely, and the deformity may increase. In certain instances 
there may be a secondary infection, tuberculous or ortherwise, 
at the seat of injury, and in others the injury may be the exciting 
cause of spondylitis deformans, but such results are unusual. 

Treatment.— In all such cases, and whenever weakness of the 
spine persists, and when motion causes pain, a support should be 
employed as in the treatment of Pott's disease. If possible, 
deformity if of recent origin should be corrected, in part at least, 

1 Boston Medical and Surgical Journal, January 2, 1902. 

2 Deutsche med. Woch., 1895, No. 11. 

3 Reuter, Archiv f. Orth. u. Unfallchirurgie, B. ii., H. 2, 1904. 

9 



130 



ORTHOPEDIC SURGERY 



either by direct traction or by recumbency before the support 
is applied. Massage and gentle exercise are of value during the 
period of recovery. Clinical evidence indicates that repair is slow, 
support, therefore, should be used for at least six months and 
for a much longer time if the injury is of the middle dorsal region 
in which the tendency to postural deformity is so marked. 




Rhachitic kyphosis. 



The Rhachitic Spine. 

The rhachitic spine has been described in the consideration 
of the differential diagnosis of Pott's disease. It most often 
develops during the first or second year of life, in children who sit 
the greater part of the time; it is, in fact, simply an exaggeration 
of the contour which is normal in the sitting posture. The typi- 
cal rhachitic kyphosis is thus a rounded projection of the lower 
region of the spine, which is more or less rigid according to its dura- 
tion. If the deformity is extreme there may be a compensatory 
backward inclination of the head, which may be accompanied 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 131 

by contraction of the posterior group of muscles, "cervical 
opisthotonos." 

Treatment. — Aside from the constitutional treatment of the 
rhachitic condition, and from the measures that should be employed 
to improve the nutrition of the muscles in general, the indica- 
tions are to overcome the rigidity and the limitation of motion 
of the spine; to support it, if necessary, during the stage of weak- 
ness; and to remove, if possible, the predisposing causes of the 
deformity. 

The correction of the deformity may be accomplished by mas- 
sage and by direct manipulation of the spine. The child is 
placed, face downward, on a table; one hand is placed on the 
projection, and with the other the legs are raised to throw 
the spine into a position of overextension. This stretching is 
performed slowly and carefully over and over again at morning 
and night, and the manipulation is followed by thorough mas- 
sage of the muscles. If the deformity is marked and if the gen- 
eral rhachitic process is still active, the recumbent posture, on a 
light frame, in an attitude of overextension may be indicated 
as described in the treatment of Pott's disease. 

For older subjects some form of light back brace may be suffi- 
cient in connection with the massage, and systematic correction 
of the deformity. 

The Natural Cure. — It may be stated that the rhachitic spine is 
to a certain extent corrected when the erect posture is assumed, 
by the inclination of the pelvis and accompanying lordosis. This 
natural cure is, however, often rather a distribution of deformity 
than a cure, for the upper part of the projection may remain as 
an exaggeration of the normal dorsal kyphosis balanced by an 
exaggerated lordosis, "the rhachitic attitude." In other instances 
the persistence of the lumbar kyphosis may induce a compen- 
satory flattening of the normal dorsal kyphosis. Thus, rhachitis 
may cause the so-called flat back as well. 

It may be mentioned that rotary lateral curvature of the spine, 
one of the common deformities induced by rhachitis, is far more 
serious than the anteroposterior curvature, with which it is occa- 
sionally combined. Its treatment is considered in Chapter III. 



1 32 OR THOPEDIO S UBGEB Y 



Infectious Disease of the Coverings or Articulations of 
the Spine. "The Typhoid Spine." 

During the course of or during convalescence from typhoid 
fever, and occasionally after apparent recovery from the disease, 
symptoms of pain, weakness, and stiffness of the back may ap- 
pear. These are caused apparently by secondary infection of 
the fibrous coverings and attachments of the spine, similar to the 
more common but more severe forms of periostitis of the tibia or 
other bones, from the same cause. There is usually pain on 
motion, reflected along the nerves. In some instances this is 
extreme, and there may be accompanying muscular "cramps " and 
spasm in the limbs, local muscular spasm, and pain on pressure 
over the aifected vertebrae. The temperature is often above nor- 
mal, with irregular and sometimes extreme fluctuations in severe 
cases. 

In many instances a neurotic element is present, induced, 
doubtless, by the preceding disease. The complication is most 
common in young adults. 

In six of sixty-eight cases tabulated by Wurtz 1 the patients 
were children, and several of this class have come under my 
observation. 

Diagnosis. — The diagnosis is usually made clear by the history 
of the disease of which it is a complication. 

Treatment. — The treatment should be symptomatic. During 
the active stage, if pain is severe, the patient should be kept in 
the recumbent position, if necessary on the stretcher frame. 
Locally, the application of the Paquelin cautery is of service. 
As soon as is practicable a back brace or other support should 
be applied, which should be worn until the symptoms have 
subsided. Recovery may be predicted, the duration of the symp- 
toms averaging about six months. Slight restriction of motion 
may persist in the more severe type of cases. 

This description applies particularly to a class of cases of a 
mild type described by Gibney 2 as typhoid spine. Disease of the 
spine complicating typhoid fever was first described by Maison- 
neuve in 1835. Terrillon 3 classifies the lesions of typhoid infec- 
tion of the spine as: 

1 Boston Medical and Surgical Journal, June 26, 1902. 

2 Gibney, Tr. Am. Orth. Assoc, v. ii. 

3 Le Prog. Med., April 12, 1884. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 133 

1. Simple periostitis. 

2. Periostitis with subperiosteal abscess. 

3. Periostitis with ostitis. 

In eight of twenty-six cases investigated by Lord 1 local deformity 
indicated a destructive process. 

Symptoms resembling those described may follow other forms 
of contagious disease, notably scarlet fever, but, as a rule, they 
are much less persistent and severe. 



Infectious Arthritis of the Spine. 

"Gonorrhceal rheumatism" of the spine is uncommon. Its 
symptoms and pathology resemble those of the typhoid spine. 
Anchylosis is, however, more common as a result than after other 
forms of infection; in fact, gonorrhoea is apparently one of the 
more common causes of spondylitis deformans. 

The treatment, aside from that of the exciting cause, is symp- 
tomatic. Local support is indicated in many instances. 

Arthritis of the Suboccipital Region. — The articulations of the 
occipitoaxoid region are sometimes affected by what appears to be 
a form of acute or subacute infectious arthritis similar in char- 
acteristics to acute rheumatism. It may follow tonsillitis, diph- 
theria, or other contagious disease. It may be distinguished from 
tuberculous disease by its acute onset and from acute torticollis 
by the fact that all motions are restricted. 

Treatment. — The treatment consists in support during the 
acute stage, followed by massage, manipulation, and exercise to 
overcome the subsequent stiffness. 



Spondylitis^Deformans. 

Synonyms. — Osteoarthritis of the spine; rheumatism of the 
spine; spondylose rhizomelique; stiffness of the vertebral column. 
Spondylitis deformans is chronic progressive affection of the spine 
terminating in anchylosis and deformity. 

Pathology. — The disease is apparently a chronic inflammation 
which affects primarily the ligaments and the periosteal coverings 
of the spine, a form of ossifying periostitis which binds the ver- 
tebrae firmly to one another (Fig. 77). It may begin on the 

1 Boston Medical and Surgical Journal, June 26, 1905. 



134 



ORTHOPEDIC SURGERY 



lateral or on the anterior aspect of the spine; it may be limited 
to a particular region, but in most instances it eventually involves 
the entire spine and often the articulations of the ribs as well. 
The intervertebral disks atrophy and the spine becomes anchy- 
losed. In some instances the margins of the cartilages prolif- 
erate and become ossified in a manner characteristic of osteo- 
arthritis of the joints. 




dylitds deformans (osteoarthritis). (Goldthwait.) 



Under the general term of spondylitis deformans are included, 
in all probability, several varieties of disease, for example: 

1. The affection of the spine may be simply one of the mani- 
festations of polyarthritis — "rheumatoid arthritis" of the spine. 

2. The spine may be involved together with one or more of 
the adjacent joints which present the characteristic symptoms of 
the so-called hypertrophic form of arthritis deformans — osteo- 
arthritis of the spine. This form has been designated by Marie 
spondylose rhizomelique, spondylos-spine, rhizo-root, melos- 



NON-TUBER OULOUS A FFECTIONS OF THE SPINE \ 35 

extremity, signifying a disease of the spine together with the 
adjoining "root" joints. 1 

3. The disease may be limited to the spine, and in such cases 
it appears to be clinically distinct from characteristic general 
arthritis or atrophic or hypertrophic arthritis. It may follow acute 
polyarthritis, it may be induced apparently by gonorrhoea or by 
other forms of infection, or by injury — " traumatic spondylitis." 
It may begin acutely, or it may be chronic in character and pro- 

Fig. 78 




Spondylitis deformans, showing the characteristic curvature of the spine. Age of the 
patient, twenty-three years. Duration of the disease three years; cause unknown. No 
other joints involved. 

gress slowly. 2 It may be limited to a particular section of the 
spine, although, as a rule, the other regions are progressively in- 
volved. 

The last class of limited spondylitis is more often seen in young 
adults from twenty to forty years of age, and in at least 80 per 
cent, of the cases the patients are males. 



1 Marie, Revue de M6d., 1898, vol. xviii. 

2 Bechterew, Neurol. Centralbl., vol. ii. p. 426. 
vember 20, 1897. 



Senator, Berlin, klin. Wochen., No- 



136 



ORTHOPEDIC SURGERY 



Symptoms. — In the ordinary cases there is usually an acute 
onset from which the patient dates the beginning of his trouble, 
often so-called lumbago, followed by a gradually increasing stiff- 
ness of tha spine and accompanying deformity. The patient com- 
plains of stiffness, weakness, pain in the loins, and of pain radi- 




Spondylitis deformans, illustrating 
the characteristic deformity. Age of 
the patient, thirty years. Spine 
rigid, with the exception of the oc- 
cipitoaxoid articulation. Duration 
two years; cause unknown. No 
joints involved. 




Spondylitis deformans in a child. 



ating forward along the ribs; sometimes of weakness in the 
limbs, headache, nervousness, and the like — symptoms that may 
be explained in part by the inflammatory process and by impli- 
cation of the nerve roots, and in part by an accompanying neuras- 
thenia. The direct symptoms are increased by jars, which are 
exaggerated by the inelasticity of the spine. The disease is 
usually progressive, and terminates finally in complete rigidity 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 137 

of the spine, which is bent into a long kyphosis, most marked 
in the upper dorsal region, the lumbar lordosis being obliterated 
in many instances (Fig. 79). 

The straightening of the spine in the middle and lower region 
exaggerates the forward thrust of the neck, and in some instances 
the patients complain of a disturbance of equilibrium, especially 
of a tendency to fall forward. 

When the disease is limited to the spine or to the spine and 
one or more of the larger joints, the occipitoaxoid articulations 
are not usually involved; but in the general form of the disease — 
" rheumatoid arthritis "- — they are often primarily affected. 

The types of the disease may be illustrated by a brief descrip- 
tion of five cases recently under observation. 

Case I. Rheumatoid Arthritis of the Spine. — In this case, 
that of a boy ten years of age, there was characteristic general 
rheumatoid (atrophic) arthritis that involved nearly every joint 
of the body. The entire spine, even including the occipito- 
axoid joints, was rigid and the head was fixed in an attitude of 
extreme torticollis. 

Case II. Osteoarthritis of the Spine ("spondylose rhizo- 
melique ")• — A man aged forty-six years, after repeated attacks 
of so-called rheumatism involving the larger joints, gradually 
became disabled because of pain and stiffness of the back and 
because of his inability to stand erect. In this case there was 
complete anchylosis of the spine, except of the small joints of the 
cervical region, and in addition the right thigh was flexed upon 
the body at such an angle that the patient could walk only with 
an exaggerated stoop. The joints of the feet were slightly in- 
volved also. No cause other than exposure to cold and dampness 
could be assigned. The symptoms were of two years' duration, 
periods of comfort alternating with disabling attacks of "rheu- 
matism." 

Case III. Spondylitis Deformans. — The spine of this patient, 
a man aged forty-six years, was absolutely anchylosed in the char- 
acteristic position. The occipitoaxoid joints were not involved. 
Fourteen years before he had suffered from a severe and pro- 
longed attack of "inflammatory rheumatism," affecting nearly 
every joint, but not the spine, and during a succeeding period 
of nine years he had been disabled several times from the same 
cause. Each illness was coincident with gonorrhoea. Five years 
before examination the "rheumatism" had involved the spine, 
and since then he had suffered from persistent "lumbago." Grad- 



1 38 ORTHOPEDIC SURGEB Y 

ually the stiffness of the spine had increased, but during this 
time he had been free from gonorrhoea, and from rheumatism 
as well. The joints were normal in appearance and function. 
This patient suffers principally from nervousness and irritability; 
he is easily startled; he feels as if his forehead was clasped by a 
tight band. His direct symptoms are pain in the loins and pain 
radiating under the shoulder-blades, increased by walking or by 
jars. His equilibrium is disturbed by the forward projection of 
the head and by the obliteration of the normal lordosis, so that 
he feels himself constantly inclined to fall forward, whether he 
is sitting or standing. 

Case IV. — In another case very similar to this, in a man aged 
thirty years, the spine had become rigid in a few months. The 
patient ascribed the disease to sleeping out-of-doors. There 
was in this case coincident tuberculous disease of the lungs. 
And in this instance the cause of the deformity may have been 
superficial tuberculous disease. 

Case V. — A man aged sixty-two years, presenting the char- 
acteristic deformity and symptoms of the subacute type, gave the 
following account of the affection: Fifteen years before he had 
suffered from "chronic lumbago." The pain and stiffness, at 
first limited to the lower region of the spine, had, with interven- 
ing periods of remission, gradually ascended, and at the time of 
examination the cervical region was the seat of the more active 
process. He had been treated by internal remedies, by baths, and 
by change of climate, without avail. He knew he had the "old 
man's stoop," but he was surprised to learn that the source of 
his symptoms was a disease of the spine. The spine was rigid, 
although not anchylosed, as indicated by the discomfort on chang- 
ing from one position to another. The occipitoaxoid articu- 
lations and the other joints were free from disease. 

This subacute form of the affection is very common, and, as in 
this instance, the patients are usually treated for rheumatism, 
muscular or otherwise, for many years before the true diagnosis 
is made. 

Treatment. — The local treatment is symptomatic. Massage 
of the muscles, hot baths, and the like may add to the comfort 
of the patient, but violent exercise or passive movements of the 
spine are harmful. Support is always indicated during the pro- 
gressive stage of the affection, and it is the only efficient remedy. 
The support may be in the form of a light brace or jacket. It is 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 139 

particularly efficacious when the disease is limited to the lower 
and middle regions of the spine. In such cases under efficient 
protection the muscular spasm subsides and motion returns in 
some degree. Even in progressive cases one may hope to pre- 
serve the lumbar lordosis, and thus lessen the general effect 
of the deformity when the spine becomes rigid. In certain 
instances in which anchylosis is not established, force may be 




Extreme posterior curvature of the spine in adolescence, showing retraction of the abdomen. 
This deformity may be mistaken for spondylitis deformans. 

employed to improve the contour of the spine, particularly with 
the aim of re-establishing the lumbar lordosis, and thus enabling 
the patient to stand erect. The patient learns by experience 
what exercises or postures increase the discomfort, and these should 
be avoided if possible. The application of a cautery is often of 
service, and self-suspension at intervals may relieve the dragging 
sensation in the muscles. Rubber heels are useful in lessen- 



140 ORTHOPEDIC SURGERY 

ing the jar. As has been stated, in some cases the disease 
remains localized, but ordinarily it extends along the spine. 
When a part of the spine becomes firmly anchylosed the local 
discomfort lessens or ceases, and is transferred to the part where 
the process is still advancing. 

Kyphosis of Adolescents. — A form of extreme kyphosis accom- 
panied by stiffness and discomfort is sometimes seen. It appears 
to be a static deformity induced by overwork in rapidly growing 
adolescents, which finally becomes fixed by accommodative 
changes in the bones and neighboring tissues. It can hardly 
be classified with spondylitis deformans, although there may be 
some difficulty in distinguishing between the two (Fig. 81). In 
favorable cases partial rectification of the deformity by force 
(the Calot operation) is indicated. Afterward support, manipula- 
tion, and exercises should be employed. 



Osteitis Deformans. 

Synonym. — Paget's disease. 

Osteitis deformans is a general disease characterized by hyper- 
trophy and softening of the bones. The deformity of the spine 
is similar to that of spondylitis deformans, but the rigidity is not 
as marked, and the discomfort is far less than in this affection. 
The disease is described elsewhere. 

Tabetic Deformity of the Spine. — In rare instances deformity 
of the spine, either posterior or lateral, appears as a complication 
of locomotor ataxia. Fifteen cases are recorded. 1 The character- 
istics of this form of osteoarthropathy are described elsewhere. 



Spondylolisthesis. 

Spondylolisthesis is a deformity in which the body of one of 
the lower lumbar vertebrae, most often the fifth, is displaced for- 
ward and downward (Fig. 82). At this point the ligamentous 
support is weakest and the upper surface of the sacrum slants 
forward. In certain instances the spinous process may remain 
in its normal position, while the laminae become elongated or 
separated from the body (Fig. 82). The condition was first de- 

1 Cornell, Bulletin of Johns Hopkins Hospital, October, 1902. 



NO N- T UBEB CULOUS AFFECTIONS OF THE SPINE 141 

Fig. 82 




Small pelvis of Prague (median section). Instance of slight forward displacement of the 
body of the fifth lumbar vertebra. (Neugebauer.) 



scribed by Killian in 1854, and it was 
thoroughly investigated by Neugebauer 
in 1890. 

The causes are congenital malforma- 
tion, injury, overstrain, and possibly 
disease of the lumbosacral articula- 
tion. Lane states that slighter degrees 
of the deformity are often observed 
among laborers. The trunk is displaced 
forward and downward in its relation 
to the pelvis. Thus the inclination of 
the pelvis is lessened or lost and the 
lumbar lordosis is absolutely or rela- 
tively increased (Fig. 83). The sacrum 
projects and the space between the 
ribs and the iliac crests is diminished. 

The typical deformity is most often 
seen in women; in fact, its chief interest 
lies in its effect upon childbirth. As a 
rule, as has been stated in the preced- 
ing section, an increase of the lumbar 
lordosis is usually attended by a certain 
degree of discomfort, pain, and limita- 
tion of forward bending. The patients 
are weak or easily fatigued. In some 
instances disturbance of equilibrium 
is a prominent symptom. Not infre- 
quently the deformity induces a swag- 
gering gait resembling that of bilateral 




Spondylolisthesis in ; 
cent, induced apparently by over- 
work. Symptoms : inability to 
bend forward and pain on fatigue, 
radiating down back of the thighs. 



142 ORTHOPEDIC SURGERY 

congenital dislocation of the hips. Such cases, or those in 
which displacement is the result of disease or injury, particularly 
if the deformity is progressive, may require orthopedic treatment 
by braces or other support. In the milder type, exercises and 
posture are, as a rule, sufficient. 



Relaxation of the Pelvic Joints. 

Goldthwait 1 has called attention to the persistent disability that 
may follow the relaxation of the sacroiliac joints most often 
incidental to pregnancy, but induced occasionally by a variety 
of other conditions, the symptoms resembling closely those 
of spondylolisthesis. The inclination of the pelvis is lost and 
the sacrum becomes perpendicular. The treatment consists in 
re-establishing the lumbar lordosis by means of the brace or 
plaster support, thus forcing the sacrum forward to its normal 
position. In milder cases a pelvic girdle may be sufficient. 



Pain in the Lower Part of the Back. 

Discomfort in the lumbar region of the character of tire, weak- 
ness, or even of actual pain is sometimes an accompaniment of 
disease or displacement of the pelvic or abdominal organs. Pain 
in this region is also a common symptom among overworked 
women. It may be induced also by weakness or deformity 
of the feet. It is particularly troublesome when for any 
reason the lumbar lordosis is exaggerated temporarily, as during 
pregnancy, or permanently, as a compensatory deformity for 
dorsal Pott's disease, or because of flexion of the thigh after hip 
disease. 

As a result of strain or other injury symptoms of pain and weak- 
ness in the lumbar region, increased by sudden motions or over- 
exertion, may be persistent and disabling. Such cases are often 
classed as chronic lumbago, but it is probable that there is in 
many instances a distinct injury of the ligaments or deep muscles 
of the spine or strain or displacement at the sacroiliac articula- 
tion, aggravated, it may be in certain cases, by rheumatism or 
other general affection of like character. 

Ludloff 2 has recently called attention to the fact that persistent 

1 Goldthwait and Osgood, Boston Med. anil Surg. Jour., May 25 and June 1, 1905. 
! Forts, auf d. Gebieteder Roentgenstrahlen, Band ix., Heft 3. 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 143 

pain about the sacrum following falls or other injuries may be 
explained in many instances by a slight degree of traumatic 
spondylolisthesis. 

The treatment must be primarily directed to the condition of 
which the pain is a symptom. 

When motion causes pain and when the symptoms are per- 
sistent, as in the lumbago type of cases, whether due to injury or 
to inflammation of the fibrous or muscular tissues, support is in- 
dicated, the Knight brace or plaster corset being convenient 
forms. During the more acute stage the application of the cau- 
tery and the support of intersecting strips of adhesive plaster, 
covering a wide area, will often relieve the pain. Later, massage, 
electricity, and the like are of service. 

In milder cases, in which the symptoms may be dependent 
on a general descent of the abdominal and pelvic organs, an ab- 
dominal belt will afford great relief. 



The Neurotic Spine. 

The "neurotic" spine is much more common in adolescence 
and in adult life than in childhood, and the subjects, usually 
females, are often of a nervous or neurasthenic type. In certain 
instances the symptoms appear to be induced by injury, and in 
others by worry or overwork. 

Symptoms. — The patient usually complains of a dull pain in 
the back of the neck, or in the lumbar or sacral region, of a con- 
stant tired feeling, and, not infrequently, of sharp neuralgic pain 
localized about a certain point in the spine, often the vertebra 
prominens. The contour of the spine may be normal, but most 
often there is a lessening of the lumbar lordosis a backward 
inclination of the body and a forward droop of the head, an atti- 
tude that signifies muscular weakness and strain upon the liga- 
ments. One of the common symptoms of the neurotic spine is 
extreme local tenderness, or hyperesthesia, of the skin at certain 
points along the spinous processes. Thus, if one passes the finger 
gently along the spine the patient will often shrink or cry out 
because of the pain. As a rule, there is no limitation of motion 
or muscular spasm. The pain is local, not referred to the ter- 
minations of the nerves; in fact, the symptoms are in great part 
subjective and irregular in character, as contrasted with those 
of actual disease, which are objective and well-defined. 



144 



ORTHOPEDIC SURGERY 



Treatment. — The treatment of the neurotic spine must be 
general in character, as indicated by the condition of the patient. 
Locally, a light back brace or a long corset, reinforced if neces- 
sary by light steel back bars, adds greatly to the comfort of the 
patient. The application of the cautery is particularly efficacious 
in relieving the local sensitiveness. Massage and light exercises 




The neurotic spine. Characteristic attitude. 

may be employed inj;he later treatment. Weak feet are often 
associated with this condition. In such instances appropriate 
treatment often induces a marked improvement in the general 
condition. 



The Hysterical Spine. 

The hysterical spine is considered usually as synonymous with 
the neurotic spine, but as there are many individuals who suffer 



N ON-TUBER CULOUS A FFECTIONS OF THE SPINE 1 45 

from sensitive spines who are not hysterical, it would seem proper 
to limit the latter term to the hysterical class. 

Symptoms. — The local symptoms do not differ particularly 
from those of the neurotic spine except that in certain instances 
actual deformity may be present. This is usually an exaggerated 
lateral distortion, most marked in the lumbar region. Like hys- 
terical distortions elsewhere, it may follow injury, and it may 
be claimed that this injury was the direct cause of the deformity. 
Except, however, as possible cause of the appearance of a par- 
ticular manifestation of the mental condition, it is evident that 
no form of injury could explain the symptoms or the deformity. 

Treatment. — The local treatment is similar to that of the 
neurotic spine. 

Deformity Secondary to Sciatica. 

Synonym. — Sciatic scoliosis. 

Chronic sciatica often induces a change in the attitude and con- 
tour of the spine that may become a permanent deformity if its 
cause persists. As a rule, the patient habitually inclines the 
body away from the painful part in order to relieve it from weight 
and bends the body slightly forward and abducts the limb to 
relax the tension on the sensitive nerve or plexus of nerves. Thus, 
the pelvis on the affected side projects, there is a lateral lumbar 
convexity toward the opposite side, and often the normal lumbar 
lordosis is lessened or lost, so that the final result may be a per- 
sistent lateral curvature, together with a change in the antero- 
posterior contour of the spine. If the deformity persists a second 
compensatory curve may appear (Fig 85). If the sciatica is a 
symptom of a more widespread neuritis, muscular weakness 
and muscular spasm may cause variations in the typical attitude, 
the muscles of one side being persistently contracted. 

It must be borne in mind that disease of the lumbar spine, 
particularly at the lumbosacral articulation, may induce similar 
distortion of the spine accompanied by pain in the limbs. Also 
that disease of the pelvic bones or joints, or of the adjacent 
organs or parts, may set up sciatica; thus, the cause of pain 
should be carefully sought for. 

Aside from the direct treatment of sciatica, support for the 
spine, preferably a light corset, may be indicated if motion aggra- 
vates the pain. If the deformity persists it should be corrected 
gradually, by repeated applications of a plaster jacket. 



146 OB T HOPE DIC SURGERY 

Neuritis in other regions of the spine may cause symptoms of 
reflected pain and local sensitiveness. These symptoms are 
increased by motion, and a certain amount of local deformity, 
similar in character to that due to sciatica, may be present. 

The treatment is similar to that indicated in the former affection. 



Sacroiliac Disease. 

Tuberculous disease of the sacroiliac articulation is a rare 
affection and extremely so in childhood. 

Symptoms. — The symptoms are pain, weakness, limp, and 
change in attitude. The pain is referred to the side of the pelvis 
or radiates over the buttock or thigh. It is increased by jars, 
by turning the body suddenly, sometimes by coughing or laugh- 
ing; and a peculiar feeling of insecurity and weakness is some- 
times complained of. As a rule, the body is inclined toward the 
sound limb; thus the pelvis is lowered on the affected side and 
the leg seems longer than its fellow. In the early stage of the 
disease there is no deformity of the limb, but if a pelvic abscess 
forms, the thigh may become flexed. Locally, there may be sen- 
sitiveness to pressure over the articulation, and swelling in the 
neighborhood of the disease, although this is usually a late symp- 
tom. Pain is induced by lateral pressure on the pelvis or by 
any manipulation that disturbs the articulation. 

Abscess finally forms in the majority of cases. It may be 
extrapelvic or intrapelvic. The intrapelvic abscess may present 
above the crest of the ilium, or the pus may pass through the 
sciatic notch, or appear in the ischiorectal fossa, or break into 
the rectum. 

Diagnosis. — Sacroiliac disease may be mistaken for sciatica 
or for disease of the hip or spine. The freedom of motion and 
the absence of muscular spasm when the pelvis is fixed, if the 
examination is carefully conducted, should exclude both the one 
and the other, although the pain on lateral pressure, which is 
described as the most characteristic symptom, may be simulated 
closely by primary acetabular disease. The attitude is similar 
to that of sciatica, but the symptoms of local sensitiveness to 
jars and to manipulation are much more marked. 

Prognosis. — According to the statistics the prognosis is very 
unfavorable, probably because the majority of the reported cases 
were in adults and were complicated by infected and burrowing 



NON-TUBERCULOUS AFFECTIONS OF THE SPINE 147 

abscesses, which constitute the chief clanger of this form of tu- 
berculous disease. 

Treatment. — The local treatment consists in protecting the 
diseased parts from injury and in the radical removal of the 





Deformity caused by persistent sciatica of 
the right side. This attitude is similar to that 
symptomatic of sacroiliac disease. 



Sacroiliac disease in a child, showing 
the extra pelvic abscess above the dis- 
eased articulation. 



disease if it has reached the stage of abscess formation, if this be 
feasible. 

In the ambulatory treatment of advanced cases a plaster spica 
bandage or a double Thomas hip brace may be indicated, but in 



148 OB THOPEDIC SURGERY 

most instances a broad, strong pelvic girdle, which may be drawn 
tightly about the pelvis, will be most efficient. As a temporary 
support wide encircling bands of adhesive plaster may be used. 
If motion of the spine causes discomfort a spinal brace provided 
with a wide pelvic band of thin steel that may clasp the pelvis 
firmly is more efficacious. If the disease is progressive, rest in 
bed will be necessary. 

When abscess is present radical treatment is usually indi- 
cated. The articulation should be freely exposed and the dis- 
eased bone should be entirely removed, if possible. Intrapelvic 
abscess should be drained through a direct communication, if 
possible, in order to check the tendency toward burrowing. 



Injury of the Sacroiliac Articulation. 

In some instances the symptoms of sacroiliac disease are 
apparently due directly to falls on the buttock or pelvis or to 
strains. In such cases there may be an actual injury or displace- 
ment at the articulation. This is particularly likely to occur if 
the articulations are relaxed as the effect of pregnancy. The 
treatment has been indicated already. The prognosis is favorable. 



CHAPTER III. 

LATERAL CURVATURE OF THE SPINE. 

Synonyms. — Rotary lateral curvature — scoliosis. 

Lateral curvature of the spine is an habitual or fixed deformity 
in which the spine is deviated in whole or part to one or the other 
side of the median line. 

By limiting the term to habitual deformity one excludes simple 
postural inclination of the spine. For example, if one leg were 
considerably shorter than the other the pelvis would be tilted 
downward on the short side, and there would be a compensatory 
curvature of the spine in the erect attitude, which would disap- 
pear in the sitting posture. This accommodative or compensa- 
tory inclination, and those of similar origin, are not, in the proper 
sense, lateral curvatures. 

In persistent lateral curvature the weight supporting part of 
the column is more distorted than are the spinous processes, 
because lateral bending is always accompanied by a certain 
degree of twisting or rotation of the vertebral bodies. This rota- 
tion is in the direction of the convexity of the curve, and, as the 
bodies rotate, the spinous processes are carried in the reverse 
direction. Thus it is that well-marked rotation may be present, 
although there may be comparatively little lateral deviation of 
the line of the spinous processes. 

In the physiological movements of the spine, simple, direct 
lateral motion — that is, motion allowed by the small joints of the 
spine and by the lateral compression of the intervertebral disks 
— is very limited. The larger movements must be accompanied 
by rotation of the vertebral bodies by which this continuous or 
solid part of the column is, as it were, forced from the shortened 
toward the lengthened side (Fig. 87). When, for example, one 
flexes the head to bring the ear as near the shoulder as is possible 
there is necessarily an accompanying rotation of the chin in the 
opposite direction caused by the twisting of the bodies of the 
cervical vertebrae toward the convexity of the curve. 

In the simple accommodative lateral inclination of the body to 
one side or the other, the change in contour of the spine would be 



150 



OR TH OPED 10 SURGERY 



more noticeable if it could be observed from the front rather than 
from the back, and as lateral curvature is simply a persistent 
deviation of the spine, one of the so-called static deformities which 
are directly induced or exaggerated by superincumbent weight, 
it may be assumed that rotation of the vertebral bodies precedes 
the lateral distortion that first attracts attention. 

It is probable, also, that slight rotation may not cause at once 
an appreciable degree of external distortion, and, although marked 
lateral curvature is necessarily combined with rotation, yet it is 




Physiological rotati 



accompanying flexion and lateral inclination of the trunk in 
the normal subject. 



possible that a slight degree of direct lateral deviation may exist 
unaccompanied by appreciable rotation. Rotation is usually 
understood to imply fixed deformity, while lateral deviation may 
mean simply an habitual posture; but it is far simpler to consider 
the two as parts of one distortion. The important distinction is 
between habitual deformity, implying the habitual assumption 
of an improper attitude in which the accommodative changes in 
structure have not advanced sufficiently to prevent voluntary or 



LATERAL CURVATURE OF THE SPINE 151 

passive correction, and fixed deformity in which the changes in 
the bones and other tissues have made cure difficult or impossible. 
The evidence of fixed deformity is rotation that persists after the 
lateral deviation has been overcome. It persists because the 
early and important changes must take place in the bodies of the 
vertebrae upon which the weight falls, but there is no reason to 
believe that habitual rotation as an accompaniment of habitual 
lateral curvature may not be corrected if it be treated at the 
proper time. 

The necessity for dividing the weight about the centre of gravity 
in order to balance the body in the upright position accounts 
for the distribution and effects of lateral curvature. As the normal 
contour of the spine is the necessary result of static conditions, 
a change from this normal relation of one part necessitates a 
corresponding change elsewhere. If there is a primary lumbar 
curvature and rotation to the left in the lower region, a corre- 
sponding lateral deviation and rotation to the right in the region 
above usually develops, thus restoring the balance of the body. 
This explains the ordinary S-shaped or double curve of scoliosis, 
one of which is primary and the other secondary. These curves 
may divide the spine equally or there may be a long and a short 
one, and occasionally three distinct curves may be present. If 
the primary curve is slight, the secondary curvature will be slight 
also, and the primary curve persists doubtless for a time before 
the secondary distortion appears. In some instances the spine 
may be bent laterally into one long curve, "total scoliosis" (Fig. 88). 
This is probably, in many instances at least, the initial stage of the 
ordinary type of scoliosis, the long curve being afterward divided, 
although it may persist. In childhood total scoliosis is often 
combined with general posterior curvature, and it is peculiar 
in that the torsion of the vertebra? may be toward the concave 
instead of the convex side, the torsion representing probably 
the early stages of the secondary or compensatory curve. 

It has been stated that deformity of one part of the spine is 
usually balanced by deformity of another. This enables the 
trunk to hold the erect posture, and it restores its general sym- 
metry. If, however, a long lateral or long posterior curvature 
persists, the weight can be balanced only by swaying the entire 
body on the pelvis, in the direction opposed to the distortion. 
This restores the balance, but not the symmetry (Fig. 102). 

Rotation and Lateral Deviation. — Fixed rotation of the spine 
carries with it, of course, all the parts that are attached to it. 



152 



ORTHOPEDIC SURGERY 
Fig. 




Congenital total scoliosis. The rotation is much greater than the lateral deviation. 
Compare with Fig. 88. 



LATERAL CURVATURE OF THE SPINE 



153 



When the patient stands in the erect attitude the simple lateral 
distortion is most noticeable (Fig. 88), but when the body is bent 
forward the twist of the trunk becomes the prominent deformity 
(Fig. 89). If the thoracic region is involved, the ribs on the 
side toward which the spine is rotated project backward, and on 




Primary lumbar curvature to the left. A "flat back" marked rotation with but slijht 
lateral curvature. 



the other side of the spine there is an abnormal flatness or 
depression. The projection of the ribs due to the twisting of the 
thorax is far more noticeable than is the simple twisting of the 
free portions of the spine in the neck or loins; and in these 
regions the projecting transverse processes covered by the thick 
layers of muscles, yet unaccompanied by marked lateral deviation, 



154 



ORTHOPEDIC SURGERY 



may cause mistakes in diagnosis. In the cervical region, for 
example, as an accompaniment of acute torticollis, the projection 
may be mistaken for abscess; and in the lumbar region it has 
been mistaken for a new-growth attached to the spine. 

Although persistent lateral curvature of the spine is always 
accompanied by rotation, the degree of rotation does not always 
correspond to that of the more evident lateral deviation. In tie 
instance cited, rotation in the lumbar region, so extreme as to 




Scoliosis with marked posterior deformity. 



simulate an abnormal growth, may exist with but slight lateral 
distortion; while in ether cases the body appears to be greatly 
displaced to one side, although there may be comparatively little 
fixed rotation. Again, as has been stated, the lateral deviation 
of the trunk is usually more noticeable than the rotation, which 
in the slightest grades of deformity is only made apparent when 
the patient is bent forward so that the back may be inspected in 



LATERAL CURVATURE OF THE SPINE 155 

the horizontal position. It may be noted, also, that the degree 
of habitual lateral distortion of the body does not correspond to 
the degree of fixed distortion. One individual, by voluntary 
effort, may practically conceal advanced deformity, while another 
who makes no effort to correct the improper posture appears to 
be greatly distorted, although the fixed changes may be very 
slight. 

The effects of the deformity, both general and local, depend 
upon its situation and its degree. In one instance it may be so 
slight as to pass unnoticed, and in another the distortion may 
equal that of Pott's disease (Fig. 91). If compensation is per- 
fect — that is, if the deformity is equally distributed on either 
side of the median line — the general symmetry of the body may 
be but slightly disturbed. Or, if the compensation for the pri- 
mary deformity of the lumbar region is distributed throughout 
the remainder of the spine, noticeable distortion may be insig- 
nificant, but when there is a long curve involving the thoracic 
region the lateral and posterior displacement cannot be concealed 
(Fig. 92). 

Changes in the Anteroposterior Contour. — Lateral distortion 
involves also secondary changes in the anteroposterior outline 
of the spine. When the distortion is marked the stature is 
shortened, especially when the anteroposterior curves are increased 
in addition to the lateral deviation. In general, one may recog- 
nize two types of lateral curvature: one in which the back is 
flatter than normal, in which the anteroposterior curves are 
diminished, and another in which they are increased. It has 
been stated in the account of Pott's disease that deformity 
in one segment of the spine always caused a change in the 
contour of the spine as a whole, that an obliteration or a lessen- 
ing of the concavity of the lumbar region was accompanied by a 
corresponding flattening of the normal dorsal kyphosis. On the 
other hand, that an increase in the backward projection of the 
dorsal region caused an increase in the concavity of the parts below. 
The variations in the anteroposterior contour of the spine in 
lateral curvature may be accounted for in the same manner. In 
the one instance the primary deformity is of the lower region, 
and with its accompanying backward twist of the vertebral bodies 
it lessens the lumbar lordosis and tends to flatten the back (Fig. 
90). If, on the other hand, the deformity begins in the thoracic 
region, the primary effect is to increase the backward projection, 
and this in turn tends to exaggerate the lumbar lordosis (Fig. 19). 



156 



OB THOPEDIO S UB GEB Y 



Thus, the shortening of the trunk in the lumbar region caused 
by the lateral deviation may be to a certain extent compensated 
in the first instance, while in the other both the primary and 
secondary distortions tend to reduce the height. 

The " High" Shoulder and the " High" Hip.— When the convex- 
ity of the primary curve is, for example, to the left in the lumbar 
region the trunk is displaced somewhat to the left, consequently 




Scoliosis with extreme lateral deviation. 



the right "hip" becomes abnormally prominent, a prominence 
that is usually mistaken for an elevation, and in compensation 
for the displacement below there is a corresponding twist in the 
opposite direction above. The spine bending, and at the same 
time rotating toward the right, carrying with it the ribs, raises the 
shoulder and makes the scapula prominent. Thus it is that in 
the ordinary S-shaped curve the high shoulder and the projecting 



LATERAL CURVATURE OF THE SPINE 157 

hip appear usually upon the same side of the body. But in less 
regular varieties of distortion, when, for example, there is marked 
general lateral deviation of the trunk as a whole, the high shoulder 
may be on the opposite side (Fig. 92). It is probable that the 
primary curvature is in most instances to the left in the lumbar 
region, the compensation to the right appearing at a later time. 
This is certainly true of the milder types of postural curva- 
ture. 

Pathology. — Lateral curvature of the spine is a deformity, 
not a disease, nor is it in the ordinary cases an effect of disease. 
For this reason the description of the pathology which is merely 
a more detailed account of the deformity and of its secondary 
effects upon the trunk and its contents may, for convenience, 
precede the discussion of the etiology. 

In such a description one must consider the spine as a whole, a 
column bent and twisted, in which each component segment bears 
its share of the general distortion. The vertebra at the apex 
of each curve shows the greatest change. If the rotation 
and lateral deviation is to the right the vertebral body is 
somewhat wedge-shaped, the apex of the wedge being directed 
backward and to the left. Its lateral diameter is increased 
and the superior and inferior margins at the narrow side pro- 
ject, increasing its lateral concavity (Fig. 96). Similar accom- 
modative changes, although less marked, are to be found in the 
articular processes and in the lamina?; in fact, all the parts on 
the concave side are broadened, shortened, and lessened in vertical 
diameter as compared with those on the convex side of the spine. 
These changes affect the shape of the neural canal, which becomes 
somewhat ovoid in outline, the base being directed toward the 
convexity of the curve (Fig. 97). In the vertebrae, included in 
the compensatory curvature, the deformities are reversed, and 
the intermediate segments show the transitional changes between 
the two extremes. The intervertebral disks become wedge-shaped 
also, and atrophied on the shortened side, the changes in these 
softer tissues preceding, undoubtedly, those in the bones. The 
articulations of the vertebrae become changed in shape and posi- 
tion in the general adaptation to the deformity and the ligaments 
are shortened or lengthened according to their relation to the 
distortion. • 

On section the internal structure of the vertebrae shows the 
same adaptive changes that are evident on the exterior. In the 
narrowed parts of the bones that bear the weight the tissue is 



158 



ORTHOPEDIC SURGERY 



thick and compact, and on the opposite side it is attenuated and 
atrophied. 

The mobility of the spine is lessened by these changes in its 
shape and structure, primarily by the distortion, secondarily by the 




shortening of the tissues on the concave side, by the irregularities 
of the vertebral bodies, by the interference of the newly formed 
or transformed bone which is thrown out about the margins of 

the vertebra 1 and the articular processes, and by ossification of 



LATERAL CURVATURE OF THE SPINE 



159 



the periosteum and ligamentous coverings of the adjacent bones. 
Thus, in fixed deformity there may be, at the points of greatest 
distortion, practical anchylosis. The muscles of the back, both 
intrinsic and extrinsic, undergo adaptative changes, and, as a 
rule, they are relatively weak. 

The distortion of the vertebral column causes, of course, a dis- 
tortion of the trunk of which it is the support, and this distortion 
is of the greatest importance in its effect upon the thorax. The 
deformity of the thorax is somewhat difficult to describe, because 




Scoliotic vertebrae. (Hoffa.) 

the distortion of the dorsal vertebrae does not affect the thorax 
equally; thus, it is not twisted as a whole, nor flexed as a whole. 
The nature of the deformity may be better understood by consid- 
ering the sternum as a fixed point; this, as a matter of fact, it is, 
as compared with the spine. At the apex of the convexity of 
the curve the ribs are drawn sharply backward; their angles 
project by the side of and beyond the spinous processes, some- 
times covering and concealing them, and the lateral convexity 
of the chest is diminished or lost. On the opposite side the 
back is broadened and flattened. The effect of the rotation 



160 



ORTHOPEDIC SURGERY. 



is to diminish the capacity of the chest on the convex side 
and to increase that of the concave side (Fig. 98). On the 
convex side the ribs are elevated and their inclination is in- 
creased. On the concave side the intercostal spaces are narrowed 
and the inclination is lessened (Fig. 95). The anteroposterior 
diameter of the chest is increased or diminished according to 
the change in the anteroposterior contour of the spine. If 
the dorsal kyphosis is exaggerated the effect is to deepen the 
chest (Fig. 91); if it is diminished, the diameter of the thorax 
is correspondingly lessened. 

The cervical section of the spine is not often involved, to a 
marked degree at least, in the lateral deformity. But in extreme 




Change in shape of the spinal canal, broade 



•ex side. (Hoffa.) 



cases, in which the neck and head are habitually distorted, the 
skull may show accommodative changes similar to those in- 
duced by persistent torticollis. 

At the other extremity of the spine the pelvis is not, as a rule, 
markedly deformed. In some instances the oblique diameter, 
opposed to the convexity of the lumbar deformity, may be in- 
creased, and if the lateral deviation of the lumbar spine is 
extreme the pelvis may be so tilted that the limb on the elevated 
side becomes practically shorter than its fellow. 

In changes that have been described the contents of the trunk 



LATERAL CURVATURE OF THE SPINE 161 

participate to a greater or less degree. The lung on the convex 
side is more or less compressed by the distorted ribs and by the 
displaced vertebral bodies. The heart may be displaced later- 
ally or in other directions according to the position of the de- 
formity, and the bloodvessels are changed in direction, and, it 
may be, altered in calibre. In those cases in which the thorax 
is markedly distorted the effect is similar to that of the deformity 
of Pott's disease; respiration is shallow and rapid, the pulse-rate is 
usually increased, and other evidences of interference with the 
vital functions may be apparent. The abdominal organs are 
affected, doubtless, in a similar manner, but symptoms due 
to this cause are not, as a rule, as clearly marked. 



Deformity of the thorax in scoliosis. (Hoffa.) 

Bachmann 1 investigated the secondary changes induced by 
severe scoliotic deformity coming under his observation in the 
pathological institute of Breslau. In 91.3 per cent, of the sub- 
jects defect or disease of the circulatory apparatus, and in 99.1 
per cent, of the respiratory organs was observed. 

Etiology. Relative Frequency. — Lateral curvature of the spine 
is One of the most common of deformities. In a period of fifteen 
years— 1885 to 1899 — 3252 cases were recorded in the out-patient 
department of the Hospital for Ruptured and Crippled, a number 
only exceeded by that of bow-legs, of which 5030 cases were 
treated during the same period. 

1 Bachmann, Die Veriinderungen an den inneren Organen bei hochgradigen Skoliosen 
u.nd Kyphoskoliosen, Bibliotheca Medica, 1900, Ab. D. 1, H. 4, 

u 



162 ORTHOPEDIC SURGERY 

The relative frequency of lateral curvature among children 
in general is illustrated by the statistics of Drachmann, who 
found among 28,175 school-children (16,789 boys, 11,386 girls) 
of Denmark 368 cases of scoliosis (1.3 per cent.), and those of 
Scholder, Werth, and Combe, 1 who found 571 cases of lateral 
curvature among 2314 school-children of Switzerland (24.6 per 
cent.), a discrepancy that is somewhat difficult to explain. 

Sex. — Lateral curvature of the spine is far more common 
among females than males. Of the 3252 cases referred to, 2554 
(78.5 per cent.) were in females and 698 (21.4 per cent.) were in 
males. 

The lowest percentage of males in any one of the fifteen years 
was 14.8, the highest 25.1. This proportion of one male to four 
females is somewhat larger than in the smaller groups of cases 
reported by other observers. 

The unequal distribution of the deformity between the sexes 
is of great interest as bearing on the question of etiology; espe- 
cially so as in the cases that develop in early childhood, sex ap- 
pears to exercise practically no influence. It has been suggested 
that curvature of the spine in a girl is looked upon with more 
solicitude by the mother than is the same deformity in a boy, there- 
fore, more girls are brought for treatment. There may be some 
basis for this argument, for it is certain that distortions of the 
lower extremities are considered of greater importance in male 
than in female children, because of the concealment to be afforded 
by the skirts, if the deformity is not outgrown. But granting 
that statistics are somewhat unreliable, there can be no doubt 
but that this deformity is far more common among girls than 
boys and that the disproportion may be explained, in great part 
at least, by the differences in dress and in manner of life. 

Age. — One thousand two hundred and ninety-nine (39.9 per 
cent.) of the 3252 patients referred to were less than fourteen 
years of age; 1576 (48.4 per cent.) were between fourteen and 
twenty-one; 377 (11.6 per cent.) were more than twenty-one 
years of age. These statistics simply show the age of the patients 
at the time treatment was sought, and they are of little value 
as an indication of the age at which deformity might have been 
detected had it been looked for. 

There is no reason to suppose that lateral curvature of the 
spine differs in its etiology from similar deformities of other 
parts, except in so far as each region of the body is more 

1 Extrait des Annals Suisses d'Hygiene Scolaire, 1901. 



LATERAL CURVATURE OF THE SPINE 163 

or less susceptible to deforming influences at one time than 
another. 

For example, rhachitic deformities of the upper extremities 
practically never develop except in infancy, and they begin to 
correct themselves when the erect posture is assumed or at the 
very time when distortions of similar origin of the lower extrem- 
ities appear or increase. When deformities of this class, whether 
of the spine or limbs, appear in later childhood or adolescence it 
may be assumed that, in many instances at least, the tendency 
toward the particular deformity, or even a slight degree of 
deformity, was acquired at an early age, that it remained latent 
until conditions appeared which favored its further develop- 
ment. This point is illustrated by the statistics of Eulenburg 
of 1000 cases of lateral curvature analyzed with reference to the 
inception of the deformity. 

Between birth and the sixth year 78 

" the sixth and seventh years 21 6 

the seventh and tenth years 564 

" the tenth and fourteenth years 107 

After the fourteenth year 35 

1000 

It will be noted that but 142 (14.2 per cent.) of these patients 
were more than fourteen years of age as contrasted with the 
statistics of the Hospital for Ruptured and Crippled, in which 
60 per cent, were beyond this age. 

Dr. Walter Truslow, who for several years had the immediate 
charge of the treatment of lateral curvature at the Hospital for 
Ruptured and Crippled, has prepared for me statistics of a 
number o£ the cases which illustrate the same point. 
A. — Age when Treatment was Begun. 

Age when examined. Males. Females. Total. 

4 years 1 1 

5 " 1 1 

6 " 1 1 2 

7 " ! 4 2 6 

8 " . . . • 4 7 11 

9 " 4 4 8 

10 " 2 7 9 

11 " 3 13 16 

12 " 3 16 19 

13 " 4 28 32 

14 " 5 25 30 

15 " 3 21 24 

16 " 8 14 22 

17 " 2 6 8 

18 " 1 2 3 

19 " 1 1 

20 " . . . 1 1 

21 " 4 4 

23 " 1 1 

24 " 1 1 

32 " 1 1 

44 157 201 



164 ORTHOPEDIC SURGERY 

B. — Age when the Deformity was Discovered. 

Males. Females. 

Congenital (sex not stated) 2 

During infancy (sex not stated) 19 

Between 3 and 6 years 16 10 6 

6 " 10 " 41 10 31 

" 10 " 13 " 62 6 56 

" 13 " 15 " 27 3 24 

Over 15 years 14 3 11 

Unknown 20 

201 32 128 

But 44 of the 181 patients (22.6 per cent.) were more than 
thirteen years of age at the time when the deformity was first 
noticed, although nearly 50 per cent, were older than this when 
treatment was applied for. In the first table it will be noted 
that of the 38 patients who were ten years of age or less, 15, or 
about 40 per cent., were males. Of 25 of the 37 cases in 
which the deformity attracted attention at or before the sixth 
year rhachitis was the apparent cause. 

Lateral curvature of the spine is one of the penalties of the 
erect posture, and the force of gravity must be considered both 
as a predisposing and as an exciting cause of the deformity. 
The more direct tendency of the force of gravity is to cause 
the body to sink forward and to increase the posterior curvature 
of the spine, but whenever there is a persistent inclination of the 
spine to one or the other side this inclination is likely to be in- 
creased to deformity under favoring conditions. These favoring 
conditions would include general weakness from any cause; over- 
work that may induce fatigue, and all factors, mechanical or 
otherwise, that may add to the difficulty of holding the trunk 
erect under the pressure of the superincumbent weight. 

Although it is not difficult to suggest the predisposing causes 
of lateral curvature, it is by no means as easy to point out the 
direct cause of the original inclination of the spine to one or tl e 
other side of the median line. In a certain number of cases, 
however, the relation between cause and effect is sufficiently 
evident, and these causes may be enumerated before considering 
the larger class in which the etiology is more obscure. 

1. Lateral curvature secondary to deformity of other parts. 

2. Static or compensatory deformity. 

3. Deformity secondary to disease of the nervous system. 

4. Deformity secondary to disease of the thoracic organs. 

5. Incidental deformity. 

6. Deformity due to occupation. 

7. Congenital deformity. 

8. Rhachitic deformity. 



LATERAL CURVATURE OF THE SPINE 165 

li. Lateral Curvature Secondary to Deformity Else- 
where. — (a) Lateral curvature of the spine may be a compen- 
satory effect of torticollis, either congenital or acquired. (6) It 
may be induced by distortion of the lower extremities. For 
example, fixed adduction of the thigh necessitates an upward 
tilting of the pelvis whenever the limb is brought into the 
normal line, whether the patient is standing, sitting, or lying; 
and this deformity when extreme may induce lateral curvature 
even in bedridden patients. 

2. Compensatory Deformity. — The same effect is sometimes 
observed in certain instances of inequality of the length of the 
lower extremities. In the erect posture the pelvis is tilted down- 
ward on one side, and this in turn necessitating a twist of the 
spine. Simple inequality of the limbs is an occasional but not a 
common cause of fixed deformity, because its influence ceases in 
the sitting and reclining postures, and because the inequality is 
so often compensated, if it is extreme, by walking on the toe or 
by raising the sole of the shoe. 

An increase in the length of a limb, such as may be caused by 
a fixed equinus of the foot, seems to have more influence in caus- 
ing secondary deformity than does shortening, because no attempt 
is made to compensate for the inequality. 

3. Lateral Curvature Secondary to Paralysis. — Lat- 
eral deformity of the spine may be caused indirectly by a number 
of distinct diseases of the nervous system, but in this connection 
only one need be considered — anterior poliomyelitis. This form 
of paralysis may act in several ways. It may induce deformity 
by distortion of a lower extremity or by inequality in the length 
of the limbs due to retardation of growth. It may predispose 
to deformity by the general weakness that it causes, or the trunk 
may be unbalanced by loss of function in one of the upper 
extremities, but the more extreme cases of deformity are caused 
by unilateral paralysis of the muscles of the trunk. As a result 
the expansion of one side of the thorax is interfered with and the 
unaffected, or less affected, side taking on increased activity, 
develops at the expense of the disabled part. Thus, the con- 
vexity of the curve is usually toward the sound part. 

4. Lateral Curvature Secondary to Disease within 
the Thoracic Walls. — The most common cause of deformity 
of this class is persistent empyema. The lung is primarily com- 
pressed by the effused fluid, and its function is finally impaired 
or abolished by the adhesions that form between it and the chest 



166 



ORTHOPEDIC SURGERY 



wall, as well as by the extension of the disease to its structure. 
As a result, the side of the chest is retracted while the function of 
the unaffected lung is increased (Fig. 99). Thus, as in paralysis, 
the spine curves with the convexity^toward the active side. 

Other affections of the lungs that interfere with the function 
of one side may induce lateral curvature, but the influence is less 
marked and direct than in empyema, 




Scoliosis following empyema at the age 
of two years. 



Present age nineteen years. Scoliosis secondary to 
lumbar Pott's disease in early childhood. 



5. Incidental Lateral Curvature. Lateral curvature 
may be caused by direct injury or by disease of the spine; for 
example, by fracture or by Pott's disease, or by other organic 
affections of the spine (Fig. 100). Distortion symptomatic of 
sacroiliac disease, or the more marked deformity caused by 
sciatic or lumbar neuritis (Fig. 85), may if persistent finally 
induce slight permanent deformity, but such eases hardly deserve 
special consideration. 



LATERAL CURVATURE OF THE SPINE 167 

6. Lateral Curvature due to Occupation .— Laterarcurva- 
ture of a mild degree is incidental to certain occupations that 
require habitual inclination of the body. It is said to be very 
common among stone-cutters, for example. Such deformity 
developing after the growth of the body has been attained is of 
interest as throwing light upon the etiology of the ordinary form 
of lateral curvature. For if habitual attitudes can thus change 
the contour of the developed spine, it is evident that similar 




Congenital scoliosis. Rhachitic scoliosis. 

postures, though far less. constant, may influence the spine of a 
growing child, particularly in one predisposed to such distortion. 
7. Congenital Lateral Curvature. — Congenital scoliosis 
is uncommon in infants otherwise normal (Fig. 101), but several 
cases have come under my observation at an age sufficiently 
early to make diagnosis absolutely certain. One case, in an 
otherwise well-formed male infant, was seen at the ap-e of three 



168 ORTHOPEDIC SURGERY 

months. There was well-marked lateral deviation with rotation 
in the dorsal region that had attracted attention soon after birth. 
A second case, in a female child, was seen at about the same 
age. The deformity was extreme, and contracted tissues on 
the concave side prevented the straightening of the spine. There 
was also an accompanying lumbar hernia. 

The first patient was cured by manipulation and posture before 
the completion of the first year; the second is still under treat- 
ment. A number of cases have been collected from literature 
by A. Perrone. 1 Lateral curvature is often associated with 
congenital defects or malformations; for example, with congenital 
elevation of the scapula, with congenital torticollis with cervical 
ribs, with rhachischisis and the like. 

8. Rhachitic Lateral Curvature. Rhachitis predisposes 
to deformity of all parts of the body by weakening resistance 
of all the tissues. As is well known, the common deformities 
from this cause are the so-called rhachitic kyphosis that develops 
in the sitting child, and the distortions of the lower extremities 
in those who stand and walk. Lateral curvature of the spine 
sometimes accompanies the kyphosis in those who do not walk, 
or it may exist independently of it. The lateral inclination is 
induced doubtless by the manner of sitting or by the manner in 
which the child is supported on the mother's arm; for at this 
period of rapid growth and increased susceptibility to deforming 
influences, even slight and temporary causes of this nature may 
be sufficient to induce the distortion (Fig. 102). Again, when 
the child begins to walk, the tilting of the pelvis due to distortion 
of the limbs, for example, to unilateral knock-knee, may also 
serve to disturb the equilibrium of the body and thus to induce 
lateral distortion. 

How common rhachitic lateral curvature may be it is impossible 
to say, but it is probable that if all rhachitic infants and children 
were carefully examined this deformity would be discovered in 
many instances in which its existence had not been suspected. 

Mayer 2 examined 220 rhachitic infants with reference to this 
point, and in all but 3 found scoliotic deformity. This is not in 
accord with my own experience, but I am convinced that rhachitis 
is of far greater importance in the etiology of lateral curvature 
of the spine than is generally believed, and that a large proportion 
of the severe and intractable cases may be traced to this cause. 

'Ueber Kongenitale Skoliose, Zeits. f. Ortho. Chir., 1906, B. xv., II. _'. 
« Hull. MOdicale. June 15. 1901. 



LATERAL CURVATURE OF THE SPINE 169 

In about 15 per cent, of the cases tabulated by Truslow the 
influence of one or more of the causes that have been enumerated 
seemed to be apparent, viz.: 

Congenital deformity 2 

Torticollis 2 

Empyema 4 

Anterior poliomyelitis 3 

Inequality of the legs of more than half an inch 6 

Rhachitis 13 

Total 30 




Posture induced by improper desk and chair. (Scudder.) 



In the remaining 85 per cent, of the cases the direct cause 
of the deformity was uncertain. 

Hereditary Influence. — By many writers the influence of heredity 
is considered an important factor in the etiology. That there is 
such an influence, predisposing to disease as well as to deformity, 
is undoubted, but it is very difficult to establish its connection 
with ordinary cases. In eleven of 201 cases, lateral curvature 
was present in either the father or mother of the patient; and in 
seventeen others a brother or sister of the patient was deformed 
in a similar manner. 



70 



ORTHOPEDIC SURGERY 



Occupation. — It is well known that occupation may induce 
deformity in the adult, and one looks naturally to occupation as 
a factor in the causation of lateral curvature in childhood. Occu- 
pation in this class implies school, and it is well known that fatigue 
during school hours may induce improper postures, especially 
if the chair is unsuitable or uncomfortable. The influence 
of habitual posture is indicated in the statistics of lateral curvature 
among school-children recorded by Sch older, Werth, and Combe, 1 
the proportion of deformity steadily rising from the lower to 




Posture induced by improper chair. (Scudder.) 

the higher classes (Figs. 103 and 104). Under the influence of con- 
stantly recurring fatigue an improper attitude is likely to become 
habitual, its character being influenced by the arrangement of the 
light or by the shape of the desk. When a habit of posture has 
been acquired it is likely to persist when the sitting posture is 
assumed elsewhere than at school, and the greater liability of 
girls to the deformity may be explained in part by the fact that 
they sew, or read, or play on the piano at times when boys are 
usually engaged in active exercise. 

In 400 cases of lateral curvature under treatment at the Hos- 
pital for Ruptured and Crippled, the occupation and habits that 
may have influenced the deformity were recorded: 



LATERAL CURVATURE OF THE SPINE \1\ 

Occupation: • 

School 285 

Factory 19 

Clerk !3 

Domestic 8 

Millinery, dressmaking, etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

No occupation 59 



Total 



Posture: 



Weight on right foot 48 

" " left " 48 

— 96 
Carries books or baby on right arm 38 

left arm 36 

— 74 

Sits at desk or work in faulty attitude 57 

Carries heavy load on one shoulder 2 

Excessive use of right arm in occupation . 3 

Total 232 



The sitting posture is not the only one in which improper 
attitudes may be persistently assumed, for even posture during 
sleep may influence the inclination of the body during the hours 
of activity. But the sitting position is the one in which the 
muscular support is most likely to be relaxed, and in which 
a tendency toward lateral inclination is most likely to be 
acquired, since children do not often retain a fixed attitude in 
the erect position for any length of time. Bradford and Lovett 
record an observation of the attitudes of sixty-seven healthy 
adults undergoing a written examination. At the end of the 
second hour a lateral inclination of the body was evident in all, 
and in three-fourths of the number the general inclination 
of the body was to the right. In about this proportion of the 
cases of lateral curvature the type of fixed deformity is to the left 
in the lumbar and to the right in the dorsal region Assuming that 
the distortion is caused or influenced by the habitual attitude 
during school hours it would appear that the primary deformity 
should be more often of the lumbar region, for in the sitting 
posture the lumbar lordosis is lessened or lost; thus the bodies of 
the vertebrae in the lumbar region are subjected to greater pressure 
than in the dorsal region — a pressure which might induce the 
accommodative changes in the bones that accompany persistent 
deformity. 

The possibility of distinguishing the varieties of lateral curva- 
ture in which the primary distortion is lumbar from those in 
which it is dorsal, by the flattening of the dorsal kyphosis in the 



172 ORTHOPEDIC SURGERY 

former, and its exaggeration in the latter instance, has been 
mentioned. 

Varieties of Deformity. According to statistics from various 
sources, about three-fourths of the well-developed double curves 
of the spine are convex to the right in the dorsal and to the left 
in the lumbar region, and, as the distortion of the thorax is more 
noticeable of the two, it usually classifies the deformity as right 
or left. The dorsal curvature may be either primary or secondary, 
and the relative frequency of the original deformity, whether lumbar 
or dorsal, is in doubt, with the probability in favor of the former. 

Summary of varieties of deformity of the spine under treatment, 
1899-1900, at the Hospital for Ruptured and Crippled, tabulated 
by Dr. Truslow: 

1. Simple anteroposterior deformities: 

(a) Kyphosis 10 

Kypholordosis 1 

Lordosis 1 

— 12 
Round shoulders: 

(6) Abducted scapula? 7 

Elevated scapulas 2 

— 9 

2. Anteroposterior abnormalities most marked, but accompanied by 

lateral deviation: 

(a) With single lateral curve 14 

(6) With double lateral curves 16 

(c) With triple lateral curves 7 

— 37 

3. Rotation more marked than lateral deviation: 

(a) With double lateral curves 22 

(6) With triple lateral curves 8 

— 30 

4. Lateral deviation more marked than rotation; direction of the 

curves: 
Right dorsal, left lumbal type: 

(o) Single lateral curve 22 

(6) Double lateral curves 17 

(c) Triple lateral curves 6 

— 99 
Left dorsal, right lumbar type: 

(a) Single lateral curve 3 

(6) Double lateral curves 8 

(c) Triple lateral curves 3 

— 14 

Total 201 

It will be noted that in twenty-one cases, anteroposterior 
deformity was present without lateral deviation, and that in 
thirty-seven instances it was accompanied by lateral deviation. 
In the remaining 144 cases, rotation was more marked than 
lateral deviation in 30 cases, and lateral deviation more marked 
than rotation in 113. In the entire number of cases in which 
lateral deviation was present it was single in 39 cases, double 
in 117 cases, triple in 24 cases. 



LATERAL CURVATURE OF THE SPINE 173 

In 890 cases of lateral curvature tabulated by Schulthess the 
deformity was as follows: 1 

Left. Right. Total. 

Total scoliosis (single curve affecting the entire spine) . 173 23 196 

Lumbar scoliosis (single curve limited to the lumbar 

region) 63 34 97 

Lumbodorsal scoliosis (single curve limited to lumbo- 

dorsal region) 184 164 348 

Complicated scoliosis: 

(o) Right dorsal, left lumbar 191 

(6) Left dorsal, right lumbar 58 ... 249 

478 412 890 

It will be noted that a very large proportion of these cases 
were in the early stage of deformity, as indicated by the absence 
of compensatory curves; that in 80 per cent, of the 293 cases in 
which the curve was general or most marked in the lumbar 
region, the inclination was to the left, and of the complicated or 
more fully developed cases in which the curve was double, 73 per 
cent, were of the right dorsal, left lumbar type. 

Symptoms. — In the large proportion of cases the first symp- 
tom is the deformity. This is often discovered by the dress- 
maker at the age when the clothing is made to fit the figure more 
closely. In certain instances the deformity may be preceded or 
accompanied by pain. This was present to a greater or less 
degree in about one-quarter of the cases examined by Truslow. 
Pain may be simply the discomfort or the "dragging" sensation 
of fatigue, usually referred to the lumbar region, or it may be 
severe and neuralgic in type. The latter variety is more common 
in the cases in which the deformity is extreme. It is said to be 
the result of pressure on nerves, but this cause is exceptional in 
ordinary cases, as it is as often referred to the convex as to the 
concave side. When the deformity is extreme — for example, 
when the ribs and the iliac crest are in contact — direct pressure 
may explain the local discomfort referred to this region. 
There are also more general symptoms of a neurasthenic or 
hysterical nature that may be due in part to the deformity and 
in part to the debility of which it may be a result or accompani- 
ment. For it must be borne in mind that lateral curvature is 
one of the postural deformities whose development is favored 
by general weakness, as illustrated by the fact that it is often 
accompanied by other deformities of similar nature, particularly 
by the weak foot. Deformities of this class which are induced 
by weakness, in their turn tend to prolong and to aggravate it 
by hampering normal development and normal function. 

1 Zeits. f. Orth. Chir.. 1902, Bd. x. 



174 ORTHOPEDIC SURGERY 

In many instances symptoms of weakness and awkwardness 
precede the deformity. Truslow states that in a large proportion 
of the casss investigated, the patients had been distinctly less 
active than their companions, that they did not enjoy exercise, 
and were inclined to lead sedentary lives. Teschner 1 has called 
attention to the same peculiarity. He states that the patients 
are often indifferent, apathetic, and lazy. He has noted also a 
peculiar lack of co-ordination and muscular control as a com- 
mon accompaniment of the deformity. These symptoms apply 
particularly to adolescence, the period of rapid growth and 
instability, when any latent deformity or weakness is likely to 
be exaggerated. In younger subjects such symptoms are far 
less marked or are absent. In the cases in which the deformity 
is extreme, symptoms due to interference with the respiratory and 
circulatory apparatus, or to displacement of the abdominal 
organs, may be present. Such symptoms are, however, rather 
unusual in cases of the ordinary type. 

Diagnosis. Posture. — Lateral curvature of the spine is a simple 
deformity unaccompanied by the symptoms of disease. When 
the patient stands with the back and hips bare, the inclination 
of the body to one or the other side and the general want of sym- 
metry are usually apparent, even in the earliest stage of the affec- 
tion. For, as has been stated, the habitual assumption of a certain 
posture precedes fixed changes in and about the spine, and this 
posture will appear when the patient is asked to stand in the 
usual manner. If the inclination of the body is toward the left 
(Fig. 88), the left arm will hang in close apposition to its lateral 
border, while on the right side an interval will appear between 
the arm and the trunk. If there is a slight lumbar curve to the 
left (Fig. 90), the right iliac crest will be accentuated. The 
curvature in the dorsal region raises one shoulder (Fig. 99), the 
scapula on the affected side projects, and the distance between 
its posterior border and the median line is increased. Rotation 
of the spine is shown by the fulness or projection of one side ac- 
companied by a corresponding flatness on the other. This is 
more noticeable when the patient bends the body forward so that 
the horizontal plane of the back is brought into view (Fig. 89). 
Corresponding changes, though of a less marked degree, appear 
on the anterior surface of the body; for example, the apparent 
diminution in the size of the mamma on the side opposite the 

1 Medical Record, December 16, 1893. 



LATERAL CURVATURE OF THE SPINE 175 

convexity of the posterior curve and its relative depression or 
elevation may attract attention. 

It seems probable that a change in the anteroposterior contour 
of the spine precedes, in many instances, the lateral deviation. 
Thus, a general droop of the body associated with round shoulders 
and a flattening of the chest may be regarded as a predisposing 
cause or an early symptom of more serious deformity. 

Mobility. — As has been mentioned, it may be assumed that 
habitual posture precedes actual deformity. Habitual posture 
implies disuse of certain attitudes and motions, thus limitation 
of the normal flexibility of the spine is one of the earliest signs 
of progressive deformity. The test of the motion of the different 
regions of the spine is, therefore, a necessary part of the examina- 
tion. To test the motion in the lumbar region, one fixes the 
pelvis with the hands while the patient sways the body in the 
four directions and rotates it from side to side. It is suggested 
by Bradford and Lovett that direct lateral flexibility may be 
tested by placing blocks of wood under one foot until the limit 
of lateral flexion is reached, as shown by the inability of the 
patient to hold the elevated limb in the extended position. The 
experiment is then repeated on the opposite side. The flexi- 
bility of the upper part of the trunk may be tested by fixing the 
part below with the hands while the patient flexes, extends, and 
rotates the body. It is important, also, to test the range of motion 
at the shoulder-joints. The normal individual should be able 
to hold the arms extended directly above the head without in- 
creasing the lumbar lordosis. In many instances, however, it 
will be found that there is a marked restriction of this motion; 
in fact, such restriction is almost always an accompaniment of 
so-called round shoulders. 

The height and weight, the circumference and the expansion 
of the chest should be investigated, and a test of the muscular 
strength, not only of the muscles of the trunk, but of the mem- 
bers as well, is of advantage as throwing light on the etiology 
and indicating the general line of treatment. 

Record. — The most reliable of the graphic records to be used 
in connection with the history are photographs. The patient 
may stand behind a thread screen (Fig. 105) in the habitual atti- 
tude. The spinous processes, the iliac crests, and the angles of 
the scapulae having been marked, the exact amount of lateral 
deviation of the trunk will be shown. The rotation may be indi- 
cated also by photographing the patient in the recumbent posture. 



176 



ORTHOPEDIC SURGERY 



The rotation of the spine is the most important indication of 
deformity. This may be recorded with sufficient accuracy by 
taking direct tracings of the trunk at fixed points by means 
of a lead or zinc tape while the patient lies in the recumbent 
posture. 

At the Hospital for Ruptured and Crippled the shadow of the 
trunk cast by an electric light at a fixed distance is traced upon 
a 1 large sheet of paper. Upon this outline the position of the 

more important landmarks is 
indicated. The degree of ro- 
tation is shown by transverse 
tracings and the line of the 
spinous processes is ascer- 
tained by applying a broad 
strip of adhesive plaster to 
the back upon which the tip 
of each spinous process is 
marked. The anteroposterior 
outline of the spine should 
be recorded, also the general 
attitude and the presence or 
absence of other evidences 
of weakness such as knock- 
knees and weak feet. 

Prognosis.— In the devel- 
opment of lateral curvature 
there is doubtless a prelimi- 
nary or predisposing stage — 
a stage of progression and a 
stage of arrest. All deformi- 
ties of this class are more 
likely to progress during the 
growing period. They are 
likely to become stationary 
when the period of growth is 
completed. Thus, the prognosis is worse when the deformity 
begins at an early age than when it first appears in adolescence. 
The most extreme and intractable of the simple cases are the 
result of rhachitis, in which the deformity appearing in infancy 
or early childhood has increased with the growth of the child. 

If the causes of deformity are such that they operate to check 
the equal development of the affected part, the prognosis is even 




The thread screen. From the Boston Children a 
1 1< i-pital Report. 



LATERAL CURVATURE OF THE SPINE 177 

more directly influenced by the age of the patient. For example, 
empyema, even if the lung is irreparably damaged, does not cause 
appreciable deformity in the adult, but in childhood the functional 
activity and the growth of the side of the thorax are checked, in 
addition to the direct effect of the adhesions and contractions due 
to the disease; thus, the deformity is likely to be progressive in 
spite of the treatment. The same is true of paralytic deformity. 
In the ordinary type of lateral curvature in the adolescent girl 
the prognosis is influenced, of course, by the general condition 
of the patient and by the character of the occupation. As far 
as the local deformity is concerned, the prognosis as regards im- 
provement or cure depends in great measure upon the fixed changes 
that have taken place, and upon the degree of voluntary and 
involuntary rectification that is possible. In some instances the 
postural distortion may be considerable, yet the fixed deformity 
may be very slight, while in other instances the fixed rotation of 
the spine may be marked, although the lateral distortion is less 
noticeable. 

A single curve is more amenable to treatment than is a double 
or triple distortion, because it indicates an earlier stage of de- 
formity and because the treatment may be more effective when 
applied to one deformity than to several. If, however, the single 
curve is fixed, the appearance of a secondary or compensatory 
curve at another part of the spine is probable, in spite of pre- 
ventive treatment. 

In the majority of cases, fixed deformity of the spine as indi- 
cated by rotation is already present when the patient is brought 
for treatment. This fixed deformity might be overcome doubt- 
less in certain cases, and complete cure might be obtained were 
all conditions favorable. But in the ordinary sense a cure means 
the relief of symptoms, the checking of the progress of deformity, 
and the restoration of the general symmetry of the trunk. Such 
a cure may be obtained in most instances. The deformity of 
the spine becomes symmetrically divided on either side of the 
median line, the changes incident to maturity, particularly the 
increased amount of adipose tissue, serve to conceal the irregu- 
larities of the outline, and the history of the distortion is completed. 

In certain instances, particularly in well-marked cases, the 
deformity may increase in adult life and even in old age. In 
such cases, the symptoms of discomfort and actual pain may be 
troublesome throughout life, especially in the overworked and 
debilitated class. The symptoms directly incident to the com- 

12 



178 ORTHOPEDIC SURGERY 

pression and distortion of the internal organs have been men- 
tioned. 

The great majority of cases that develop or that are discovered 
in adolescence progress for a time and come to an end on the 
cessation of growth, causing finally no symptoms other than the 
loss of symmetry that may be more or less satisfactorily concealed 
by the art of the dressmaker and by the corset. 

It would appear, then, that lateral curvature of the spine is 
always of sufficient gravity to merit treatment and supervision 
until its cure or arrest is assured. If its discovery leads to active 
efforts to improve the general condition and to avoid unhealthful 
influences it may be even of benefit to the patient. 

Lateral curvature in a young child is of far greater importance 
than in an older subject because of the probability of an increase 
of deformity. Extreme deformity is always a source of weakness 
and usually of discomfort to the patient. Incipient deformity 
may be cured and cure is not impossible even when deformity 
is more advanced, but in this more than in any other postural 
deformity, absolute cure implies early diagnosis and prevention, 
rather than the correction of fixed distortion. 

Recapitulation. — It seems probable that in the ordinary type 
of lateral curvature of the spine, the first step is a change in the 
relation of the bodies of the vertebrae to one another; that a 
persistent lateral inclination and rotation of the anterior part of 
the column precedes the lateral inclination of the trunk which 
first calls attention to the deformity. This postural distortion 
becomes fixed by accommodative changes in the muscles and other 
tissues about the spine, and, finally, it is confirmed by changes 
in the shape of the vertebral bodies and by the general changes 
in the trunk as a whole. Thus, if one might observe the incep- 
tion and development of lateral curvature of the common type 
he would note, first, that the trunk was more often flexed to one 
side than to the other, and that this attitude gradually became 
habitual. Lateral inclination of the trunk necessitates, of course, 
lateral deviation and rotation of the bodies of the vertebra?, and 
the habitual assumption of such a posture implies disuse of other 
postures and thus disuse of normal motion. 

Disuse of motion in any direction is followed by diminished 
power in the inactive muscles, and, as has been stated, habitual 
deformity is followed by accommodative changes to a greater or 
less degree in the various tissues whose functions have been 
changed or modified. 



LATERAL CURVATURE OF THE SPLXE 179 

Thus the progress of the deformity would be shown: 

1. By the habitual assumption of an attitude simulating 
deformity. 

2. By limitation of motion in the directions opposed to the 
habitual attitudes. 

3. By fixed lateral deviation of the spine accompanied by 
rotation or twisting of the column. 

One rarely has the opportunity to note the development of 
lateral curvature, and when patients are brought for treatment 
fixed deformity is usually present. It is extremely difficult to 
entirely overcome fixed distortion, while it is comparatively easy 
to correct simple postural deformity in which the secondary 
changes are absent or but slightly advanced. On this account it 
is customary to divide lateral curvature into two classes — the 
true and the false — or to speak of rotary lateral curvature as 
distinct from lateral curvature. Thus, the term true or rotary 
curvature would be limited to those cases in which the changes 
are fixed and in which cure is practically impossible, while false 
or simple or postural lateral curvature would include the early or 
curable class. But as the two forms are simply stages in the 
same process it would seem preferable to speak of the incipient 
and the later stages of lateral curvature, or of reducible or irre- 
ducible deformity, the distinctions that are made in classifying 
distortions of similar origin elsewhere. 

This point of view is of advantage because it relieves the sub- 
ject of much of the obscurity that has resulted from this arbitrary 
division. It emphasizes the fact, also, that the habitual assump- 
tion of an improper attitude that simulates deformity is the first 
step toward permanent distortion, particularly in individuals who 
by inheritance or by constitutional tendency or by occupation are 
predisposed to it. 

The Prevention of Deformity. — Prevention includes the avoid- 
ance of all the predisposing or exciting causes of weakness as 
well as of deformity. These it is hardly necessary to enumerate. 
The first and most important preventive measure is the dis- 
covery of deformity or the tendency to deformity at a time when it 
may be checked or cured. To discover deformity at this period 
of its development one must look for it, and it would seem that 
regular inspection of the naked bodies of all children should 
become a routine practice of the family physician. Deformity 
in this sense includes not only fixed distortions, but improper 
attitudes and postures of every variety as well. 



180 



ORTHOPEDIC SURGERY 



The importance of the attitude which is habitually assumed 
during occupation has been mentioned. Therefore, the provision 
of proper desks and seats for school-children is a very essential 
part of preventive treatment. 

The seat of the chair should be deep enough to support the 
thighs, yet it should not interfere with flexion at the knees. It 
should be of such height as to allow the feet to rest firmly on the 
floor, and it should be inclined slightly backward. The back of 
the chair should extend to about the level of the shoulders; it 
should be inclined slightly backward, but arched somewhat for- 
ward in the lumbar region in order to conform to the normal 
lordosis when the child sits in the erect posture. The desk should 
be as close to the body as is possible, so that the child need not 




Adjustable school desks and seats. Scheiber and Klein. (Ri'dard.) 

lean for forward when reading or writing. The height of the 
desk should be slightly less than the level of the elbows when 
the child sits erect, and the inclination should be sufficient to 
hold the book at the proper distance from the eyes (Figs. 106 
and 107). The vertical handwriting is of advantage in that the 
children are taught to face the desk squarely, as contrasted with 
the lateral twist of the body, the usual attitude for writing. 

Treatment.— The treatment of rotary lateral curvature of the 
spine does not differ in principle from the treatment of any other 
weakness or deformity, but the application of this principle is 
difficult and the results are for from definite and satisfactory. 
This explains, doubtless, the apparently opposing theories and 
methods of treatment that are still advocated. 



LATERAL CURVATURE OF THE SPINE 



181 



The principles of the treatment of any form of weakness not 
directly induced by disease are, then: 

1. To overcome all restriction to passive motion. 

2. To strengthen the weakened muscles, especially those whose 
action is opposed to habitual deformity. 

3. To insist on the avoidance of overfatigue and improper 
postures. 

4. To support the weak part by a brace if deformity cannot 
be prevented otherwise. 

In applying these principles to the treatment of the distorted 
spine the first step, the removal of restriction to passive motion 

Fig. 107 




Adjustable school seat. (Miller and Stone.) 

in all directions, is difficult because of the variety of muscles and 
other tissues that may have become involved, and because the 
bodies of the vertebra? lying within the trunk, of which the dis- 
tortion is always greater than of the spinous processes, can be 
only indirectly affected by voluntary or by passive movements. 
The cultivation of the muscular system, and particularly of 
those muscles whose action is opposed to the habitual deformity, 
is the second indication in treatment. As applied to the treat- 
ment of the weak foot, for example, in which the adductor and 



182 ORTHOPEDIC SURGERY 

extensor muscles are at fault, this treatment is simple, but as 
applied to the trunk it is difficult, because there are in nearly all 
developed cases two curves, the one primary and the other second- 
ary, in direction directly opposed to one another. These op- 
posing curves are supplied in great part by the same muscles, 
and it is difficult by voluntary effort to straighten the convexity 
of one without at the same time increasing that of the other. 

The third principle in treatment is the avoidance of predispos- 
ing attitudes and of overwork. This again may be more easily 
applied to the treatment of the weak foot; first, because it is 
relieved from strain when the sitting posture is assumed, and be- 
cause active use, as in walking, may be utilized as an exercise 
for strengthening the muscles. But the muscles of the trunk are 
not exercised to any extent in ordinary walking, which is for 
many individuals the only form of activity, nor is the spine re- 
lieved from weight when the patient is seated. On the con- 
trary, it is in this restful attitude that the deformities of the spine 
are usually most marked. Thus, only in the recumbent attitude is 
the spine entirely relieved from strain, and even at such times the 
deformity may be favored by the habitual attitude of the patient. 

The weak foot may be supported by a brace, which does not in- 
terfere with its activity, but which, on the contrary, aids normal 
motion by holding the bones in proper relation to one another. 
But in the treatment of the spine the conditions are quite differ- 
ent, since it cannot be supported without at the same time 
restraining its normal motion. Finally, no brace applied to the 
trunk is efficient, for while it may prevent the lateral deviation 
it can exercise little direct action on the rotation of the spinal 
column. 

This comparative method of exposition has been adopted in 
order to illustrate the fact that it is not the difficulty of formu- 
lating principles, but the difficulty of applying them that makes 
the therapeutics of rotary lateral curvature of the spine perplex- 
ing. In practice one must recognize the limitations of all systems 
of treatment as applied to this particular deformity, and select 
and combine methods that may be most applicable to the par- 
ticular case under treatment. 

For example, in the treatment of rhachitic scoliosis in a young 
child one cannot count upon the voluntary assistance of the 
patient; therefore, treatment by simple gymnastic exercises is 
impracticable. In this class of cases forcible correction of the 
deformity and retention by a plaster support, combined with 



LATERAL CURVATURE OF THE SPINE 183 

massage, and even the removal of superincumbent weight by 
recumbency on the stretcher frame would be treatment of selec- 
tion. At this age the trunk is flexible and the deformity may 
be progressively reduced by forcible manipulation, followed by 
fixation of the trunk in the improved position. By such means 
one may expect at this period of rapid growth to induce a trans- 
formation of the deformed vertebral bodies to an approximation 
at least of the normal. The correction of this deformity which 
must almost inevitably increase with the growth of the patient 
would quite outweigh the disadvantage of depriving the muscles 
of their normal stimulus during the corrective period of treatment. 

In the ordinary type of scoliosis in older subjects, particularly 
if the distortion is moderate in degree and the changes in the 
bones but slight, one would expect to attain the best result by 
gymnastic training and by regulation of the postures. Although 
even in this class supports may be of service, if by such means 
the trunk may be held in an overcorrected attitude until the 
deformity habit is overcome. 

The advisability of a change of occupation has been mentioned. 
It is probable that if the patient with incipient or even more 
pronounced curvature of the spine were removed from school, 
were transferred to the country where during the succeeding years 
of childhood and adolescence much of the time might be passed 
in active exercise in the open air, the final result would compare 
very favorably with that attained by active treatment under less 
favorable circumstances. Such complete change of occupation 
and surroundings is, of course, impracticable in most instances. 
Lateral curvature of the spine is not a serious disease, it is simply 
an insidious distortion which rarely causes more than compara- 
tively slight discomfort. It is usually overlooked in the incipient 
stage when it might be checked or cured, and when the deformity 
finally attracts attention it is often no longer amenable to cor- 
rection. Under these circumstances, with the uncertainty that 
exists as to the ultimate prognosis, the tediousness of treatment 
which cannot offer the assurance of definite cure, it is not strange 
that the affection is not one for the treatment of which any con- 
siderable sacrifice is considered essential. 

A third class of cases would include the fixed deformity in older 
subjects, many of whom are obliged to assume in their occupations 
attitudes that predispose to deformity. In the treatment of this 
class a support to relieve discomfort and to prevent exaggerated 
distortion may be essential. 



184 ORTHOPEDIC SURGERY 

Thus, there are three classes or types of scoliosis in which 
distinct methods of treatment may be employed. 

1. Curvatures in very young children, in which forcible cor- 
rection and fixation are indicated in the hope of correcting the 
deformity of the bones and curing the distortion. 

2. The milder degrees of deformity for which treatment by 
exercises and if possible by favoring postures is that of selection, 
and in which support is a temporary and incidental adjunct. 

3. Fixed deformity in older subjects, and those cases caused by 
disease; as, for example, by paralysis, by empyema and the like, 
for which constant support might be required. 

As a rule, however, no absolute therapeutic distinction can be 
made, and treatment by exercises and by postures should be 
employed whenever practicable in all cases, whether supports are 
used or not. 

Posture and Exercises. — Whatever may have been the original 
cause of the distortion of the spine and whatever may be its 
degree it is more marked when the patient is fatigued. Fatigue 
in the normal individual is shown by the increase in the normal 
anteroposterior curves; fatigue in the deformed subject causes an 
increase in the pathological curves. It requires far more mus- 
cular effort to hold the deformed spine in the best possible attitude 
than to hold the normal spine in the correct posture. Motion in 
the normal spine is as free in one direction as in another, and it 
simply requires a proper balancing of the muscular force to hold 
it in the median line. But when there is a fixed deformity, to 
overcome which, even in part, requires the conscious effort of 
the patient, it is evident that on the relaxation of this effort the 
spine will sink back into the habitual posture. The more con- 
firmed the deformity the greater must be the effort to overcome it, 
and the more rapidly will fatigue be manifest. Fatigue, or, rather, 
the relaxation of conscious muscular effort, is favored by attitudes 
that do not require the balancing action of the muscles. For 
example, the sitting posture during school hours favors deformity, 
while the constant alternation of postures in work or play that 
requires muscular activity opposes it. Thus, the selection of 
occupations, or, at least, the restriction of the time passed in 
inactive postures, is an important part of treatment. 

As improper attitudes are favored by weakness of muscles, and 
as the maintenance of the best possible position requires a greater 
expenditure of muscular force than is required in the normal 
individual, the strengthening of all the muscles of the body, and 



LATERAL CURVATURE OF THE SPINE 185 

particularly of those of the back, by gymnastic exercises, even 
beyond the normal standard, is the most important indication in 
treatment. 

One of the most effective systems of treatment of lateral curva- 
ture is that advocated by Teschner, of New York. On the theory 
that lateral curvature is induced by or that its development is 
favored by a general lack of muscular strength and lack of mus- 
cular control and co-ordination, Teschner urges the necessity of 
the systematic cultivation of all the muscles of the body as well 
as those of the trunk, the part particularly at fault. He also 
insists upon the importance of exercising each muscular group to 
the point of fatigue on the theory that a muscle cannot be 
developed to its full capacity unless it is thoroughly fatigued by 
uninterrupted automatic contractions and relaxations. The term 
automatic implies that the patient shall be so thoroughly trained 
in the rhythmical movements that they require no thought for 
their performance. Thus, ease and grace may replace awkward- 
ness and inco-ordination. 

The system advocated by Teschner is modified from one taught 
by Attilla, a "trainer of strong men." It consists of a series of 
exercises with light dumb-bells, and it is supplemented by so-called 
heavy work. The exercises are designed for systematic cultiva- 
tion of all the muscles of the body, the heavy work more directly 
for the correction of the deformity of the spine. 

General Exercises. — The exercises should be performed before 
a mirror, the patient being clad in a close-fitting rowing suit, so 
that the attitudes may be constantly observed by the patient and 
by the instructor. The greatest attention is paid to the perfection 
of the alternating movements of the limbs in order that they may 
become in time purely automatic in character. During the per- 
formance of the exercises the patient holds himself in the best 
possible position. 

These exercises were described and illustrated by Teschner in 
the Annals of Surgery for August, 1895, from which they are, 
with his permission, reproduced. 

"A pair of dumb-bells, weighing from one-half to five pounds 
each, according to the ability of the patient, is used in a series of 
twenty-six exercises. 

"The Exercises. — The patient stands erect, the heels together, 
the toes apart, the knees thoroughly extended, the abdomen 
retracted, the chest high, the head well poised, and the patient 
looking intently and sharply into his or her own eyes in the mirror, 



186 



ORTHOPEDIC SURGERY 



the lips being evenly, but not too firmly, closed, and the facial 
muscles in repose. The patient should breathe easily and regu- 
larly while exercising (Figs. 108 and 109). 




"1. The upper extremities are fully extended downward, the 
forearms supinated, the elbows remaining close to the sides of the 
body, and the upper arms being fixed ; the forearms are alternately 
and automatically fully flexed and extended, the wrists and entire 



LATERAL CURVATURE OF THE SPINE 



187 



body being fixed and immovable. Twenty to fifty times (Fig. 
110). 

"2. The same position and exercise, except that the forearms, 
are fully pronated, and remain so during alternate flexion and 
extension. Twenty to fifty times (Fig. 111). 

"3. Both bells over the shoulders, the arms abducted at right 
angles to the body and in the same vertical and horizontal planes, 
the forearms fully flexed upon the arms, and the wrists fully 
flexed upon the forearms. The forearms and wrists are then 
alternately and automatically extended and flexed. Ten to 
twenty times (Fig. 112). 





"4. The same position and exercises, except that both upper 
extremities are flexed and extended at the same time. Five to 
fifteen times (Fig. 113). 

"5. Both upper extremities fully extended forward on a level 
with the shoulders, the dorsum of the hands outward. They are 
then fully and forcibly abducted on a horizontal plane, the patient 
at the same time raising the body upon the toes, and are then 
permitted to recede to the original position, the body resting on 
the toes and heels, the elbows and wrists still rigid, the bells not 
being permitted to touch as they approximate each other. Five 
to ten times (Figs. 114 and 115). 

"6. Bells in the position of exercises No. 3 and No. 4. The 
arms are fully extended alternately above the head. Ten to 
twenty times (Fig. 116). 



188 



ORTHOPEDIC SURGERY. 



"7. Bells in front of the thighs, forearms pronated, and bells 
alternately raised to the level of the shoulders, the elbows and 
wrists being fixed. Ten to twenty times (Fig. 117). 




LATERAL CURVATURE OF THE SPINE 



189 



"8. The arms abducted at right angles to the body, the bells 
rotated rapidly and forcibly forward and backward, the elbows 
being fixed. Five to ten times (Fig. 118). 





190 



ORTHOPEDIC SURGERY 



"9. The arms abducted atjight angles to the body, the thumbs 
upon one ball of each bell, the hands circumducted forward from 
above downward, the ball upon which the thumbs rest describing 
circles, the elbows and shoulders being fixed. Five to ten times 
(Fig. 119). 

"10. The same as No. 9, the hands being circumducted back- 
ward. Five to ten times (Fig. 119). 

"11. The bells to the side. Right face upon left heel, then 
placing the foot at right angles to right foot opposite the arch, 
the knees slightly flexed, the right hand at waist-line against 
the body, the bell being perpendicular. Second part of motion: 
strike from the shoulder to level of the face, advancing a step 





upon the left foot, rapidly extending the right thigh and leg, the 
right foot being fixed upon the floor, and quickly back to position. 
Ten to fifteen times (Figs. 120 and 121). 

"12. Exactly the reverse of No. 11. Ten to fifteen times. 

"13. Bells extended above the head, palmar surfaces looking 
forward, bending down to the floor, the knees remaining extended, 
and return. Five to fifteen times (Figs. 122 and 123). 

"14. Bells downward at the sides, raising and dropping the 
shoulders. Ten to twenty times (Fig. 124). 

"15. Bells downward at the sides, flexing the spine laterally, 
first to the right and then to the left. Ten to twenty times (Fig. 
125). 



LATERAL CURVATURE OF THE SPINE 



191 



" 16. Both arms are extended forward to about forty-five 
degrees and abducted at about the same angle, then forcibly 
crossed in front of the chest, causing the pectoral muscles to con- 






tract vigorously, the elbows and wrists being fixed, and then back 
to the original position. Five to twenty times, alternating the 
right and left hands above (Fig. 126). 



192 



ORTHOPEDIC SURGERY 



"17. Bells at the sides, palmar surfaces looking forward. 
Extend arms backward in a vertical plane as forcibly as possible, 
holding them rigid in the fully extended position for a few moments, 
and then returning the bells to the sides. Five to fifteen times 
(Figs. 127 and 128). 

"18. Bells to the sides. Raise the body upon the toes and 
sink to the original position. Ten to twenty times (Fig. 129). 

"19. Same position. Raise the toes as far as possible from 
the floor, the body remaining erect. Ten to twenty times (Fig. 
130). 

"20. Same position. The patient squats, abducting the knees 
and resting upon the toes, the heels being raised, the trunk per- 





fectly erect, then resuming first position. Five to twenty times 
(Fig. 131). 

"21. Same position. Standing upon left foot. Flexing the 
right thigh to a right angle to the body, extending the knee and 
ankle fully. The patient squats on the left ham, the left heel 
remaining on the floor, and then resumes the first position. Two 
to five times (Fig. 132). 

"22. The same standing upon the right foot. Two to five 
times. 

"23. The same position. Alternately and forcibly flexing the 
thighs and legs, causing the knees to touch the shoulders. Ten 
to twenty times (Fig. 133). 



LATERAL CURVATURE OF THE SPINE 



193 



"24. The same position as in No. 21, extending the right 
lower extremity, the right bell inside the thigh, the right foot 
moved in a circle on a horizontal plane to complete extension 






backward, and resuming the first position. Two to five times 
(Figs. 134 and 135). 

"25. The same as No. 24, standing upon the right foot. Two 
to five times (Figs. 134 and 135). 

13 



194 



ORTHOPEDIC SURGERY 

Fig. 136 




"26. The patient lying supine upon the floor, the lower 
extremities fully extended, the bells resting upon the chest, then 
raising the trunk to the sitting position, the lower extremities 




Scoliosis of an advanced type accompanied by dyspnoea and cyanosis. (.Teschner.) 



LATERAL CURVATURE OF THE SPINE 



195 



remaining extended, and the eyes being fixed upon the ceiling, 
and returning to the original position, touching the back of the 
head only on the floor; thus the hyperextension of the spine is 
maintained. Five to twenty times (Fig. 136)." 




Ihe same patient swinging 3C-pound bell, showing the muscular development. 
(Teschner). 



I consider these floor exercises especially useful, and, in prac- 
tice, add several others to those described by Teschner, viz.: 

27. The patient lying as in Fig. 136, lifts each fully extended 
leg alternately a distance of about two feet from the floor, then 
lets it slowly sink to its original position. Ten times. 

28. Both limbs together. Five times. 



196 



ORTHOPEDIC SUBOEBY 



29. The patient lying extended in the prone position, places 
the palms of the hands on the hips and "looks at the ceiling," 
overextends the spine as much as possible, then sinks slowly to 
the original position. 

30. Each leg fully extended is lifted upward alternately as far 
as possible (hyperextension at the hips). Ten times. 




■ ■ . *m 

WW 





The patient pushing 25-pound bells; the 
right arm up. (Teschner.) 



The patient pushing 25-pounrl bells; the 
left arm up. (Teschner.) 



31. Hyperextension at both hips simultaneously if possible. 
Five times. 

"When the patient has become proficient in these exercises, 
they should be done at home every morning and evening. 



LATERAL CURVATURE OF THE SPINE 197 

"The Heavy Work. — Bells, weighing from five to eighty 
pounds each, and steel bars and bar-bells, weighing from twenty- 
six to over one hundred and eleven pounds, are used in different 
ways. Bells are pushed from the shoulders above the head alter- 
nately as often as the patient is able (Figs. 139 and 140). 

"The patient is instructed to swing a heavy bell with one hand 
from the floor above the head and down again, the elbow and 
the wrist being fixed, and the motion repeated as often as possible 
in a systematic manner; then with the other hand the same num- 
ber of times and later with both. This exerts all the extensor 
muscles from the toes to the head in rapid succession." 

(For this exercise the patient stands firmly, with the legs 
astride of the heavy bell, and then, bending over, he seizes it and 
throws the extended arm upward entirely by the action of the 
back muscles. The bell is poised for a moment above the head, 
and it is then swung downward, carrying the extended arm 
between and behind the legs.) 

"When a heavy bell is pushed or swung above the head on 
the side opposite the scoliosis, the action of the back muscles, to 
sustain the weight and equilibrium, is such as to cause the curved 
spine to approximate a straight line (Fig. 140). A similar result 
is produced when a heavy weight is held by the side of the erect 
body on the scoliotic side, the arm being at full length. 

"When a heavy bar is raised above the head with both hands 
the patient must fix the eyes upon the middle of the bar to main- 
tain an equilibrium. This necessitates the bending of the head 
backward, the straightening and hyperextending of the spine, 
and consequently correcting a faulty position with a weight super- 
imposed. The heavier the weight put above the head, whether 
with one hand or with two, the more the patient must exert him- 
self or herself to attain and maintain a correct or an improved 
attitude in order to sustain the equilibrium. (By an improved 
attitude I mean the greatest amount of correction of the devia- 
tion of the spine that the fixation of a deformity will allow.) 
Hence, the greater the weight, the more forcible the actions of 
the muscles become, and the greater the temporary reduction 
of a deformity. It is by means of frequent and forcible tempor- 
ary reductions of deformities, by voluntary muscular action, 
that we can hope to improve, and do improve, those cases which 
are amenable to any form of active treatment. 

"When a patient, lying supine upon the floor, raises a heavy 
bar above the head so that the arms are perpendicular to the 



198 



ORTHOPEDIC SURGERY 



floor, the weight of the bar, the position and weight of the body, 
and the action of the muscles tend to broaden the entire back 
and shoulders, and a slow downward movement tends to widen 
the entire chest, and most markedly at the shoulders. The fre- 
quent repetition of the upward and downward movements plays 
an important part in the rapid development of the chest and 
back. Pushing the bells above the head, swinging them with 
each hand separately and with both hands together, raising a bar 
above the head, standing and lying down, and the exercises 
before enumerated, constitute one day's work. 

Record of the Work Performed by a Girl Fourteen Years 
of Age (Teschner). 















50-lb. bar above the 




Regu- 




Swinging 






head. 


Pate, 


lar 
exer- 


Pushing 
two 10-11). 


with each 
hand one 


Swinging 
with both 


Pushing 
two 20- lb. 




1895. 






cises. 


bells. 


15 lb. bell. 


hands two 


bells. 




Lying 




Bells. 




right to lei t. 


15-lb. bells. 




Standing. 


down. 


April 6 


3 lbs. 












•• 9 




100 


10-10 


5 




Instructed. 


Instructed. 


•' 11 


" 


150 
2 15-lb bells 


25-25 
120-lb bell 


15 


iVi 


2 


5 


•' 13 




5i 


25-25 


25 


12 


5 


10 


" l(i 


" 


51 


30-30 


35 


18 


7 


12 


" 1S 


" 


60 


33-85 

1 25-1 h. bell 


41 
2 20-1 b. bells 


20 


7 


15 


" 2'- 


" 


70 


20-20 


20 


30 


10 


15 


" 25 




!MJ 


22-22 


25 


33 


15 


1G 


" 27 




100 


35-33 


30 


50 


17 


20 


" 30 




no 


50-51) 


85 


(W 


20 


22 


May 2 


• ■ 


120 


60-GO 


3G 


70 


211 


25 








1 30-lb. bell 




2 25-lh bells 


61-lb. bar 


64-lb. bar 


" 4 




140 


ao-20 


40 


25 


5 


10 


" 7 




150 


25-25 


4> 


30 


7 


12 


" 14 


" 


lf>0 


27-27 


5.1 


34 


<l 


13 


•• Hi 


" 


170 


30-30 


55 


40 


10 


14 



"As the amount of work performed by a patient depends 
upon the last previous record of that patient, that record must be 
improved upon at each succeeding visit, unless there be a good 
reason to the contrary. Most patients can well stand three 
treatments a week (vide table). In mild, habitual cases im- 
provement in deportment is noticed by the patient's relatives 
and friends and by the patients themselves within the first two 
weeks. In these cases two months' treatment usually suffices to 
effect a 'complete' cure. In the more severe cases such rapid 
results cannot be expected, but a certain appreciable improvement 
is effected, and the amount of improvement depends upon the 
persistent continuance of the treatment. When there is fixed 
rotation of long standing, with bony and ligamentous changes, 
the prospect is not as good; but even in those cases consider- 
able improvement will be evident." 



LATERAL CVEVATUBE OF THE SPINE 199 

"Patients are not permitted to wear supports of any kind, not 
even corsets. They should not exercise until at least two hours 
after a meal, nor when menstruating. The general health is 
improved by the exercises; the patients gain in height and 
weight. The girth and breadth measurements, chest depth, 
strength tests, and lung capacity are generally increased, and the 
depth of the abdomen is usually decreased. In some cases, es- 
pecially those of undersized patients, the increase in height is 
very rapid, and it is certainly more than the increase by ordinary 
growth. There were marked cases of flat foot which were bene- 
fited. The flat feet became shorter through the exercises by the 
increase in depth of the inner arches." 

This system of exercises combines the forcible correction of 
deformity and the overcoming of restriction of normal motion by 
means of the "heavy work" with muscle building. It has the 
merit also of making an immediate mental impression upon the 
patient which no other system can make; for if the patient does 
not "strain every nerve" he must certainly exercise every muscle 
to preserve the equilibrium while supporting the heavy weights, 
and this mental impression is, undoubtedly, one of the important 
elements in successful treatment. 

The system has the disadvantage, if disadvantage it may be 
called, of making class work impossible, for the patient must be 
under constant supervision, not only that he may be urged to 
the limit of his capacity, but that overstrain may be avoided as 
well. 

It might appear from the description that the danger of over- 
work is great, but in a long series of cases, some of which were 
complicated by defects of the heart and lungs, no unfavorable 
symptoms have been observed by Teschner. The system is, 
however, one that can only be practised by a physician. 

Another system of exercises, modified somewhat from the 
so-called Swedish system, more suitable for class work is that 
followed at the Hospital for Ruptured and Crippled. Dr. Truslow 
has outlined for me some of the more important exercises, and 
illustrated them with the photographs that are reproduced here. 

The objects of the treatment are: (1) To overcome the patient's 
faulty habits of posture by the repeated purposeful assumption 
of proper postures; in other words, to counteract the deformity 
habit by training the mental and muscular perception of symmetry. 
(2) To stimulate and to strengthen the weakened muscles, par- 
ticularly those muscular groups that are especially concerned in 



200 



ORTHOPEDIC SURGERY 



overcoming the deformities, and which, for the present purpose, 
may be considered as weak. 

For convenience of description the exercises are divided into 
two classes: (1) self-correction; (2) muscle building. 




Typical lateral curvature. Hi 



LATERAL CURVATURE OF THE SPINE 201 

Self -correction ; Postures. — The first exercises (a and b) in self- 
correction are for the purpose of overcoming the anteroposterior 
deformities that usually accompany lateral deviation of the spine. 

(a) Head Bending Backward. — In this exercise the chin is 
not tilted upward, but, the head being held level, the neck is 
drawn directly backward until the cervical and upper part of the 
dorsal segments of the spine are completely extended. Thus, 
by increasing the distance between the points of attachment of 
the sternomastoids and the scaleni, strong traction is made upon 
these muscles with the effect of elevating the upper part of the 
thorax — an important feature in the exercise. 

(b) Trunk Bending Forward and Trunk Raising. — The 
patient stands in the erect posture with the spine extended and 
the chest expanded as in the previous exercise. The trunk is 
then bent forward (similar to Fig. 146), the only motion being 
at the hip-joints. The trunk is then raised again to the former 
position, care being taken to keep the hips farther back than the 
chest. In both flexion and extension the spine must be rigidly 
held in the corrected attitude, and there must be no motion at the 
knees. There is, of course, a movement corresponding to exten- 
sion at the ankle-joints when the legs and buttocks are thrown 
backward to compensate for the forward bending of the body. 
The object of this exercise is to train the patient to keep the hips 
back and the chest forward. 

The other exercises in self-correction are for the purpose of 
overcoming lateral deviation of the spine, the right dorsal, left 
lumbar curve being taken as the type (Fig. 141). 

This series is arranged in a progression, and each one must be 
learned before the next in order is attempted. 

(c) Left Neck Firm. — The left hand is placed behind the 
neck, the left shoulder is raised, and the left elbow is held well 
back. This posture impresses upon the patient the necessity of 
approximating the left shoulder and the neck (Fig. 142). 

(d) Body Inclination to the Left. — This is a most impor- 
tant posture; it is intended to correct mechanically the faulty 
inclination to the right and to overcome the upper curve by trac- 
tion on its concavity. The patient holding the arm in the first 
position is instructed to stretch well out with the left elbow, 
rotating upward and abducting the left scapula as much as pos- 
sible. This puts upon the stretch the rhomboidei and the lower 
half of the trapezius of the left side, thus making strong traction 
upon their points of attachment in the dorsal concavity. At the 



202 



ORTHOPEDIC SURGERY 



same time the patient is directed to sway the pelvis to the right. 
This usually requires assistance at first, for it brings into action 
certain deep back muscles, over which one has ordinarily but 
little control. The shoulders must be kept level and the proper 




Left neck firm. 



relation of the head and neck to the left shoulder must not be 
disturbed in this forced stretch to the left (Fig. 143). 

(e) Chest Pressing with the Right Hand. — The patient 
holding the left arm in the first position presses the right hand 
firmly against the dorsal convexity. This posture may be em- 



LATERAL CURVATURE OF THE SPINE 



203 



ployed to advantage if there is a long right dorsal curve, when it is 
an efficient aid to the left-sided pull of the two former exercises. 
(/) Right Neck Firm. — The right hand is placed behind the 
neck, without, however, disturbing the improved position induced 
by the first exercises. With both hands placed behind the head, 




Body inclination to the_left. 



the arms being in a symmetrical position, there is better mechani- 
cal fixation of the head, neck, and upper part of the trunk during 
the next exercise (Fig. 144). 

(g) Left Hip Twisting Backward. — In posture (d) the 
pelvis was swayed slightly to the right; it is now twisted slightly 
backward on the left side to overcome the twist in the lumbar 



204 



ORTHOPEDIC SURGERY 



spine which usually throws this side of the pelvis somewhat for- 
ward. This correcting motion should be carried out in the lower 
dorsal and lumbar segments, and it should not affect the attitude 
of the remainder of the trunk. 

(h) Left Oblique Stride Standing. — The pelvic twist and 
right-sided sway being rigidly maintained, the left foot is placed 
about two foot-lengths forward and a little outward. Upon this 




Right neck firm. 



leg the greater part of the weight of the body in now supported 
This allows a slight downward tilt of the pelvis to the right, and 
lessens the left lumbar convexity (Fig. 145). The positions, 
attained by the progressive exercises to this point, being main- 
tained, the patient continues with — 

(t) Trunk Bending Forward. — In this posture, motion takes 
place in the hip-joints only, as in the first exercise. This exer- 



LATERAL CURVATURE OF THE SPINE 



205 



cise further emphasizes the symmetrical position of the head and 
neck, the left-sided inclination of the upper half of the trunk, 
the right-sided inclination of the lower half, the twist and down- 




Left oblique stride standing. 



206 



ORTHOPEDIC SURGERY 



ward tilt of the pelvis (Fig. 146). The return to the improved 
standing position should be made in this order: (1) trunk raising; 
(2) replacement of the left foot; (3) return of both arms to the 




Trunk bending forward. 



sides. This is done slowly and carefully by the patient, who 
attempts to maintain the improved posture. 

The postures constitute a progression which cannot be learned 
in less than seven treatments; often much more time is required. 
As each part is learned it should be practised at home until the 



LATERAL CURVATURE OF THE SPINE 207 

next treatment, when a new posture is added, if it appears that 
progress can be made. 

These successive postures are in reality exercises in that it 
requires constant muscular effort to retain them, but they are not 
exercises in the sense of repeated alternations of position. The 
series is simply an elaboration of what is called the keynote 
posture. The raising of the left elbow, for example, makes it 
easier for the patient to overcome the distortion of the upper 
part of the spine; it also instructs him in the manner of holding 
the spine in the improved position after the arm is placed by the 
side. 

The same is true of all the postures ; each one suggests and makes 
correction easier, and after sufficient practice the patient should 
be able to assume the corrected position without placing the arm 
or the leg in the preliminary attitude. Thus the successive 
postures are, as it were, letters, which, placed together one by 
one, make a complete word, or the best possible position that the 
patient can assume. At first the patient must use the letters and 
slowly spell out the corrected attitude, but after the muscles have 
been educated by the repeated assumption of each posture, and 
when the perception of symmetry has been acquired, the corrected 
attitude may be assumed at will. Finally, the improved posture 
will be instinctively retained, and will become habitual. 

Muscle Building Exercises. — In the treatment of lateral curvature 
one aims to strengthen : 

1. The posterior cervical muscles. 

2. The dorsal and lumbar muscles. 

3. The muscles of vertebroscapular attachment. 

4. The abdominal muscles. 

5. The thigh and leg muscles. 

6. The chest expanding muscles. 

The following exercises have been selected as best adapted for 
this purpose. Each one should be performed five or more times 
according to the strength, of the patient. 

(a) Opposite Standing, Head Bending Backward, Re- 
sisted. — The patient stands before a wall or a shoulder-high hori- 
zontal bar, on which the hands are placed with the arms extended. 
The head is bent forward, and is then forced backward, the latter 
movement being resisted by the hand of the surgeon. This 
exercise is designed to strengthen the posterior cervical muscles. 

(b) Opposite Bend Standing, Trunk Raising, Resisted. — 
The patient stands with the upper part of the thighs in contact 



208 OB THOPEDIC S UB OEB Y 

with a table or horizontal bar. The hands are placed behind the 
neck and the body is bent forward on the hip-joints as in the 
first exercise. The surgeon, standing behind, places his right 




"Opposite bend standing," trunk raising, resisted. 

hand over the posterior dorsal prominence and his left over the 
lumbar projection. The patient then raises the trunk to the erect 
position against the combined resistance (Fig. 147). With a 



LATERAL CURVATURE OF THE SPINE 209 



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210 ORTHOPEDIC SURGERY 

little practice the surgeon learns to give an outward twisting 
motion to his hands while resisting, which tends to untwist the 
spinal rotations. When the dorsal rotation to the right is marked 
this untwisting may be facilitated by encircling the patient's chest 
with the left hand, while with the right, strong forward and out- 
ward pressure is made as the patient raises the body. This exer- 
cise is for the purpose of developing the muscles of the erector 
spina? group. 

(c) Prone Lying, Head and Shoulder Raising "the Seal." 
— The patient lies upon a table or upon the floor, and raises the 
head and chest — "looks at the ceiling." Progression is made 
in the increased leverage of arm-weight transference. 

1. With the hands on the backs of the thighs. 

2. With the left hand behind the neck and the right hand on 
the back of the thigh. 

3. With both hands behind the neck, and with the elbows 
well out and back. 

4. "Swimming." The arm motions of swimming, in three 
counts. This exercise is to strengthen the muscles of the back 
from the head to the pelvis. 

(d) Prone Lying, "Diving." — The patient lies upon a table 
the trunk and pelvis projecting beyond its edge, the limbs being 
fixed by a strap or by the weight of another person. The body 
is then bent downward and is raised again to the horizontal posi- 
tion (Fig. 148). In this exercise assistance will be required 
at first. Progression is made by transference of arm weights, as 
in the former exercise, thus: 

1. With the hands on the hips. 

2. With the arms stretched out at right angles to the body. 

3. With the hands behind the neck. 

4. With the arms extended in the line of the body. 

This exercise is for the purpose of strengthening all the muscles 
of the back. 

(e) Prone Lying, Leg Raising. — The patient, lying in the 
prone posture upon the floor or table, lifts the limbs (overextends) 
alternately, the raised leg held perfectly straight. When the left 
thigh Is extended, as much as the iliofemoral ligament will allow, 
the left side of the pelvis is tilted upward also, thus untwisting 
the lumbar spine. Progression in this exercise is made as follows: 

1. Alternate leg raising, unresisted. 

2. Alternate leg raising, resisted. 

3. The leg motions of swimming in three counts. 






LATERAL CURVATURE OF THE SPINE 211 

In this exercise the entire lower extremities must project be- 
yond the supporting table. The exercises are for the purpose of 
strengthening the lumbar muscles and the extensors of the thigh. 

(/) Opposite Sitting, Backward Bending of the Trunk. — 
The patient is seated upon a bench, and the feet are fastened to 
the floor. The trunk being held in a position of complete exten- 
sion, is bent slowly backward, motion being at the hip-joint only. 
Progression. 

1. With the hands behind the hips. 

2. With the left hand behind the neck, the right hand on the 

hip. 

3. With both hands behind the neck. 

4. With both arms extended upward. 

At first the body is bent backward about forty-five degrees, later 
until the head touches the floor. This exercise is to strengthen 
the abdominal muscles. 

(g) The Horizontal Bar. "Pull-ups." — The patient 
hangs by the hands and is assisted to "chin the bar." The body 
is then allowed to sink slowly back into the former position, the 
elbows are held well back, and the patient is instructed to bear 
as much of the weight as is possible with the left arm and shoulder. 
This exercise corrects the dorsal curve by means of muscular 
activity, and the lumbar curve by the weight of the suspended 
pelvis and limbs. The muscles used are those with vertebro- 
scapula attachment. 

(h) Left Leg Standing, Pelvis Tilting. — The patient 
stands upon the edge of a bench, supporting the weight on the 
left leg, the right leg being suspended beyond the side of the 
bench. While the head and trunk are kept in the corrected 
position, the pelvis is made to tilt sharply downward on the right, 
by lowering the right leg, while the left is kept perfectly stiff 
This has the effect of straightening the lumbar curve. 

(i) Left Leg "Hopping." — Both hands are placed behind 
the neck and the weight is supported entirely upon the ball of 
the left foot. In this attitude the patient hops ten or more times. 
This exercise, like the last, tends to straighten the spine and to 
strengthen the muscles of the left leg, which are often somewhat 
weakened from disuse. 

(j) Respiratory, Half Reclining, Arm Extensions and 
Flexions, Resisted. — The patient sits in a chair with an inclined 
back, or lies upon a low table with hard pillows under the mid- 
dorsal region, so that the upper dorsal and cervical segments of 



212 



ORTHOPEDIC SURGERY 

Fig. 149 




Lateral ourvature, 

1 i... 150 




The ~:iin<- patient, showing fixr.l rotation to 1 1 1 « - right in the thoracic region. (See Vie.*. 151 
Mini 152, illusi rating a simple corrective exercise thai may do carried out by i he patient. > 



LATERAL CURVATURE OF THE SPINE 213 

Fig. 151 




The patient shown in Figs. 149 and 150 inclines the body to the right, pressing the projecting 
ribs in with the right hand. (See Fig. 152.) 




In the posture shown in Fig. 151, the patient inclines the body forward. The correction 
is illustrated by comparison with Fig. 150 in the same position. 



214 ORTHOPEDIC SURGERY 

the spine must be overextended. The arms are stretched upward 
and backward, and the hands are grasped by the surgeon, who 
stands behind and resists the patient's downward pull. With the 
upward stretch of the arms and pull by the surgeon the patient 
inhales forcibly. With the downward pull against resistance 
the patient exhales forcibly. This exercise is made in the rhythm 
of slow breathing. 

When the patient has been thoroughly instructed in self- 
correction and in the exercises for muscle building, general gym- 
nastics for systematic motor training may be given effectively 
to groups of fifteen or twenty pupils. 

The exercises illustrated on pages 186-194 will serve this 
purpose satisfactorily. 

These two systems of treatment by gymnastics have been 
selected as the most practicable of the many that have been de- 
vised. It may be stated that any treatment that makes the spine 
more flexible, that overcomes faulty attitudes, and that streng- 
thens the muscles, must be of benefit to the patient, the degree 
of benefit corresponding to the persistence and energy of the 
pupil and the instructor rather than to any particular theory 
on which such treatment is based. The rotation of the vertebral 
bodies is increased by forward bending of the trunk, and, as this 
is the more important element of lateral curvature, it is evident 
that extension or overextension of the spine, combined with lateral 
twisting in such a manner as to reverse the habitual inclination, 
will most directly lessen or correct the distortion. If improvised 
exercises are conducted from this standpoint they will always be 
effective (Figs. 151 and 152). 

The Removal of Superincumbent Weight. — The removal of super- 
incumbent weight by the assumption of the reclining posture 
whenever the patient is fatigued is an important adjunct in the 
treatment of a certain class of cases. The patient should lie, 
preferably, upon a hard support in the supine posture, with the 
arms extended above the head. If the dorsal kyphosis is exag- 
gerated, a firm cushion between the shoulders or under the pro- 
jecting ribs will aid to expansion of the chesl and favor the cor- 
rection of the deformity. 

Self-suspension. — Self-suspension, by means of the halter 
and pulley, is of service in overcoming secondary contractions of 
the tissues, and thus it aids in the correction of deformity. It 
is often efficacious, also, in relieving the discomfort that is some- 
times a troublesome symptom when the distortion is extreme* 



LATERAL CURVATURE OF THE SPINE 



215 



While the patient is suspended forcible manual correction of the 
deformity can be applied to advantage. 

Suspension from the horizontal bar^ acts in a similar manner, 
although it is less effective than when the traction is made upon 




Self-suspension, illustrating the effect of traction in lessening deformity induced 
by paralysis. (Gibney.) In such cases support is essential. 

the entire spine. In this form of suspension the bar should be 
oblique in direction, the high side for the low shoulder. Thus, 
a passive "keynote" is induced while the patient is suspended. 
Exercises in this position, for example, flexion, extension, and 



216 OR THOPEDIC SURGERY 

abduction of the thighs, swaying the trunk from side to side, 
"chinning" the bar, and the like, are useful. 

The Use of Braces or Other Supports. — In the treatment of the 
ordinary type of lateral curvature, when there is an opportunity 
for proper systematic gymnastic training, direct support is not 
usually indicated. There are, however, cases even in this class 
in which the deformity habit is so persistent, and in which the 
voluntary efforts of the patient to assume a better attitude are 
so ineffective, that support may be employed for a time with 
advantage. 

The best support is a plaster corset applied with as much manual 
corrective force as is practicable while the patient is suspended in 
the upright posture if lateral deviation is most marked or if the 
curvature is flexible; in the horizontal preferably if the rotation 
is the prominent feature of the deformity. 

If correction is attempted in the horizontal attitude the patient 
may be suspended in the prone posture on a strip of cotton cloth 
(the hammock method). As this sinks under the weight the 
trunk falls into the attitude of overextension, which is that 
most favorable for the untwisting of the rotated spine. "When 
the deformity is marked, the body may be suspended in the lat- 
eral attitude by means of a sling of cotton cloth passed about the 
prominent ribs; thus the weight of the body acts as a correcting 
force during the application of the corset. 

i In using such corrective force one endeavors, if possible, to 
overcorrect the habitual deformity and the less marked changes in 
the anteroposterior contour as well. For example, if the lumbar 
region is flat one attempts to reproduce the normal lordosis, and 
if the body is habitually inclined in one direction one endeavors 
to sway it to the opposite side, and to efface the so-called high hip. 

This attitude of overcorrection assured by the corset, combined 
with exercises, is especially efficacious from the curative stand- 
point in the treatment of single flexible curves. If the second or 
compensatory curvature has already appeared, one attempts to 
overcorrect the primary deformity and directs exercises for the 
purpose of straightening the second curve while the patient is 
wearing the (Directive corset. For as the compensatory curva- 
ture is usually in the dorsal region, it may be considerably influ- 
enced by postures of the arms and shoulders. As often as pos- 
sible during the day the patient should endeavor to improve upon 
the attitude which the corset enforces, by assuming the keynote 
position and by flexing and extending the trunk at the hips. 



LATERAL CURVATURE OF THE SPINE 



217 



For general exercises the corset may be removed, and, as a rule, 
it need not be worn at night, although in the treatment of young 
subjects its constant use for one or more weeks is of service in 
enforcing a proper attitude. 

When the deformity is dependent upon irremediable injury or 
disease, such, for example, as anterior poliomyelitis or empyema, 
some form of brace must be employed constantly to prevent exces- 
sive lateral deviation of the trunk; and in cases of fixed deformity 
in older subjects, especially if the patient's occupation is fatiguing, 
a support may be indicated to relieve symptoms of discomfort or 
pain. 

Support is employed primarily with the aim of preventing an 
increase of deformity and to relieve symptoms incidental to the 




, The Knight spinal brace, as used in lateral curvature. A. leather or canvas band, made 
adjustable by lacings, is stretched from the posterior upright to the side bar on the side of 
the dorsal convexity. 

deformity. It may serve, also, in some degree as a corrective 
appliance. If it holds the spine in the extended position or 
induces lordosis, it may, by relieving the anterior portion of the 
column in part from the deforming influence of superincumbent 
weight, induce or permit a slight lessening of the rotation of the 
vertebral bodies. On this principle a light steel brace, after the 
Taylor model, may be as effective as any of the more complicated 
appliances, as was suggested many years ago by Judson. Corsets 
of other material than plaster, for example, of paper, or of alumi- 
num, as suggested by Phelps, may be employed when the de- 



218 



OR THOPEBIC SURGERY 



formity is fixed and when no change in the position or size of 
the trunk is to be expected. The Knight brace, when carefully 
adjusted, appears to meet the requirements fairly well, and when 
less support is needed an ordinary corset strengthened by light 
steels may be sufficient. 

Forcible Correction of Deformity. — In the treatment by gymnas- 
tic exercises the patients are supposed to overcome by voluntary 

effort, as far as is possible, the 
secondary accommodative con- 
tractions of the soft parts that 
prevent the correction of the 
deformity, the heavy work of 
the Teschner system being par- 
ticularly effective for this pur- 
pose. But in many instances 
the voluntary correction of de- 
formity may be supplemented 
with advantage by the employ- 
ment of force. For example, 
the patient may use the weight 
of the body as a means of 
correction by forcibly flexing 
the trunk over a padded bar 
(Fig. 162), and a variety of 
similar postures, either active 
or passive, with or without 
suspension, may be utilized 
with the same object. Correc- 
tive force applied by the hands, 
the patient's trunk being flexed 
and rotated in the directions 
opposed to the deformities, 
although the most effective 
method, is the most fatiguing, 

Forcible correction by means of the modified j v^oph^po V>flVP bppn POT1- 

Hoffa appliance. (Bradford and Brackett). anQ maCUmeS na\e Oeen COn 

structed with the aim of apply- 
ing the force in a similar manner. This is illustrated by the 
appliance of Hoffa, which has been modified by Schede and 
others. In this machine the patient is suspended, the hips 
are fixed, and the pressure screws are applied upon the con- 
vexities of the double curve, with the aim of untwisting the 
spine. The correction is maintained for fifteen minutes or longer, 




LATERAL CURVATURE OF THE SPINE 219 

and it is then followed by the regular exercises of the day 
(Fig. 156). 

The Forcible Correction of Deformity Combined with Fixation. — 
Forcible correction and fixation in the improved position is the 
treatment of selection for resistant lateral curvature in early 
childhood, because one cannot command the co-operation of the 
patient in maintaining the proper attitude, and because the rapid 
growth at this age, which favors the increase of the deformity, 
is equally favorable to its cure if the static conditions can be 
changed. 

For example, one treats the severe rhachitic kyphosis of in- 
fancy by fixation on the stretcher frame in the attitude of over- 
extension, and by daily manual correction of the deformity. 
And in the treatment of older children, in whom posterior or 
lateral deformity is fixed, one is justified in using the same method 
for its relief and cure that would be employed in the treatment of 
Pott's disease. In this class the plaster-of-Paris jacket, applied 
while the trunk is held in the best possible position, is the treat- 
ment of selection — a treatment that should be continued until 
the deformity is cured or until further rectification by this means 
is found to be impossible. 

The most convenient method of applying the jacket is by means 
of the ordinary suspension apparatus. The back having been 
carefully padded at the points of pressure, the patient is sus- 
pended, and while traction and manual corrective force are ex- 
erted the plaster bandages are applied. In this correction two 
points are of especial importance: to attain as much extension or 
overcorrection as possible, and to sway the entire body in the 
direction opposite to the habitual inclination. By overextension 
one removes the weight in part from the vertebral bodies that 
are primarily deformed, and by lateral correction one endeavors 
to change the relation of the weight to the distorted part. This 
improved position must be carefully maintained by the hands 
until the plaster bandages have become firm. The jackets may 
be changed at intervals of about a month, and at each applica- 
tion one attempts to improve upon the former position. 

Lovett 1 has urged the importance of correcting anteroposterior 
deformities by straightening the compensatory curves. For 
example, if a dorsal convexity is accompanied by a lumbar con- 
cavity the jacket should be applied while the lumbar segment is 
straight. This may be accomplished by supporting the trunk in 

1 Transactions American Orthopedic Association, 1901, vol. xiv. 



220 ORTHOPEDIC SURGERY 

the prone posture on a hammock, the legs hanging downward on 
either side, or in the sitting posture. The effect of flexion of 
the thighs in straightening the lumbar spine is illustrated in 
Fig. 157. Theoretically, if this attitude persists, it should 
induce a flattening of the abnormal kyphosis of which the lordo- 
sis is the effect, particularly if the improved position is favored 
by appropriate postures and exercises. 

In the cases in which corrective force is employed the jacket 
is used in preference to the corset, because it holds the spine 
more perfectly. It is, of course, a disadvantage to employ such 
restraint, but, as has been stated, the prognosis in fixed rotary 
lateral curvature in a young child is, as regards ultimate deform- 




Congenital scoliosis. After treatment for three years by forcible correction and 
fixation by plaster jackets. Showing the disappearance of the rotation. 

ity, extremely unfavorable, and one is justified, therefore, in 
sacrificing muscular activity in order that the original deformity 
of the bones may be remedied. As an illustration of persistence 
in this method of treatment, it may be stated that it was 
continued by me for nearly five years in one case of extreme 
scoliosis of congenital origin, with most gratifying success 
(Fig. 157). 

The jackets may be applied, also, in the horizontal position, 
traction being exerted upon the arms and legs, combined with 
manual pressure on the trunk, somewhat after the manner of the 
Calot method of correction of the deformity of Pott's disease. 
Or the body may be supported by a sling or other appliance. In 
certain instances one is able to correct the deformity more effect- 



LATERAL CURVATURE OF THE SPINE 221 

ually by horizontal than by vertical suspension in the manner 
already described. 

When the deformity has been overcome, or when the contin- 
uation of the treatment seems undesirable, the jacket may be 
replaced by a corset, which may be removed for dailymassage and 
for exercises. This may be finally discarded when the muscular 
strength has been regained. 

As has been stated, forcible correction and fixation is essen- 
tially a treatment of deformity in early childhood. But in cer- 
tain instances, when, for example, the deformity is extreme or is 
increasing rapidly, it may be employed in adolescence. In the 
treatment of this class of cases the plaster jacket is usually applied 
while the patient is fixed in the best possible position by means of 
some form of pressure apparatus, as is illustrated in Fig. 156. 

Forcible correction of deformity in this manner, under anaes- 
thesia, with subsequent fixation of the trunk and of the head, if 
possible, in the overcorrected position, is advocated by Wullstein, 1 
and it may be of service in certain cases. 

The Volkmann Seat. — In cases of primary lumbar curva- 
ture, or when the secondary curve of this region is pronounced, 
the attitude may be improved and the deformity may be cor- 
rected in part by seating the patient on an inclined plane, the 
high side beneath the low hip, thus lessening the convexity of 
the curve. 

The High Shoe. — The same object may be attained in the 
erect posture by the use of a higher heel, or heel and sole. The 
elevation may be from a half-inch to an inch and a quarter, the 
amount being regulated by its effect upon the contour of the 
trunk. 

Posture and Support during Recumbency. — The atti- 
tudes habitually assumed during recumbency should be investi- 
gated. The bed should be provided with a hard mattress and a 
low pillow, and the patient should be encouraged to lie habitually 
upon the side which opposes the deformity, or upon the back. 
The rectification induced by such an attitude may be still further 
increased by the use of a hard pillow beneath the convexity or 
beneath the back, and in certain instances the Barwell sling may 
be employed with advantage. 

General Treatment. — The importance of improving the gen- 
eral condition of the patient by regulation of the diet, by cold 
baths, and by active exercise in the open air is self-evident. The 

1 Zeit. f. Orthop. Chir., 1902, Bd. x., H. 2. 



222 ORTHOPEDIC SURGERY 

strain upon the back should be lessened by providing proper 
seats and by limiting the time passed in passive attitudes, and by 
lessening, as far as possible, the restraint of the clothing. These 
precautions are of almost equal importance with the active treat- 
ment. 

The Duration of Treatment. — The duration of treatment depends, 
of course, upon the character of the deformity and upon its causes. 
In the ordinary type of adolescent scoliosis the duration of active 
treatment is usually from three to six months. In this time the 
muscles may be so strengthened and the necessity for constant 
attention to the attitudes may be so impressed upon the patient 
that the simple exercises which may be performed at home may 
be sufficient. In such exercises the most important postures are 
those which hyperextend the spine. The constant effort should 
be to make motion in one direction as free as in another, and to 
practice postures that tend to reduce deformity. In all cases it 
is well, if possible, to keep the patient under supervision during 
the period of growth. 



CHAPTER IV. 

DEFORMITIES OF THE SPINE (Continued). DEFORMITIES OF 
THE CHEST. THE FUNCTIONAL PATHOGENESIS 
OF DEFORMITY. 

Variations in the Contour of the Spine. 

One recognizes a certain contour of the spine as normal, but 
there are variations from this type which, within certain limits, 
can hardly be classed as abnormal. Two of these have been 



The hollow round back. (Stafel.) 





The round back. (Stafel.) 



mentioned: the round back (Fig. 159), in which there is a gen- 
eral forward droop most marked at the shoulders, and the hollow 



224 OR THOPEBIC SURGERY 

round back (Fig. 158), in which the dorsal kyphosis and the lum- 
bar lordosis are somewhat exaggerated. A third type is the 
flat back (Fig. 90), in which there is neither a lumbar lordosis nor 
a dorsal kyphosis. In the marked cases there is an actual promi- 
nence in the lumbar region, while the scapula? project backward, 
overhanging the flattened dorsal spine. This type of back is the 
result, in many instances, of a rhachitic kyphosis which was most 
prominent in the lumbar region, and it often follows a primary 
lateral rotation of the lumbar vertebrae. The flat back and the 
rcund back predispose to lateral curvature. Deviations from 
the normal contour of the spine are attended by a change in the 
inclination of the pelvis and in the relation of the support of the 
limbs and trunk. The round back (Fig. 159) is almost always 
indicative of weakness, and it is often accompanied by other 
postural deformities, especially often by weak feet. 

Anteroposterior Deformities of the Spine. 

Kyphosis. — As has been stated in the chapter on Pott's disease, 
the spine is practically ' straight at birth. If during the early 
weeks of life an infant be placed in the sitting posture the head 
falls forward and the spine bends into a long posterior curve, 
the posture of weakness. The normal anterior convexity of the 
cervical section is established when the gain in muscular power 
enables the infant to hold the head erect, and that of the lumbar 
region when the pelvis is tilted downward by the extension of 
the thighs in the erect posture. 

In the erect posture the constant tendency of the weight of the 
head and of the thoracic and abdominal organs is to draw the 
spine forward and to re-establish the original posterior curve. 
This tendency is resisted by the action of the posterior muscles 
of the trunk. Whenever, therefore, the muscular power is les- 
sened or the body is overburdened, or whenever the spine is 
weakened by disease, the tendency toward the original curve of 
weakness becomes apparent (Fig. 160). Thus, the causes of an 
abnormal increase in the posterior curvature of the spine are very 
numerous. It is, as has been stated, the characteristic attitude 
of weakness, as is illustrated in infancy and in old age. It is 
one of the common occupation deformities of adult life; it is a 
common postural deformity of childhood and adolescence. It 
may be induced by a variety of diseases that lessen the resistance 
of the spine or that interfere with its function. For example, 



DEFORMITIES OF THE SPINE 



225 



by rhachitis, spondylitis deformans, osteitis deformans, Pott's 
disease, and affections of a similar nature. 

The kyphosis of rhachitis is most marked in the lower re- 
gion, that of spondylitis deformans may involve the entire spine, 
while the simple postural curvature is most marked in the upper 
dorsal region — "round shoulders." In a number of the postural 
deformities the increase in the dorsal kyphosis is balanced by an 
increased lordosis, and in this form there is simply an exaggera- 




Marked posterior curvature of the spine apparently induced by weakness incidental 
to illness. 



tion of the normal curves of the spine — the "hollow round" 
back. In other instances there is a general forward droop of 
the trunk in which the lumbar lordosis may be lessened; this 
form is more common in childhood — the "round" back. 

The forms of kyphosis that are the direct result of disease 
have been described elsewhere. Postural kyphosis — "round 
shoulders" — is one of the common deformities, and in childhood 
its etiology is similar to that of lateral curvature, of which it may 

15 



226 



ORTHOPEDIC SURGERY 



be a predisposing cause. Round shoulders and the accompany- 
ing flat chest may be induced also by obstructions in the respira- 
tory passages, such as enlarged tonsils, adenoids, and the like, 
or by bronchitis or heart disease. Another predisposing cause 
is clothing that prevents the full expansion of the chest and the 
extension of the arms, and even the weight of clothing suspended 
from the shoulders may be a factor in the etiology. These and 
other possible contributing causes should be investigated in all 
cases of this character. 

A marked type of deformity is sometimes seen in adolescents 
(Fig. 161), induced apparently by posture and by overwork, 




'.Posterior curvature of the spine in adolescence with rigidity. A deformity that may 
be mistaken for that of spondylitis deformans. 

although in most instances it may he assumed that a slighter 
deformity of long standing serves as a predisposing cause. In 
this type the deformity is resistant, and there is, as a rule, pain 
or discomfort most marked in the lumbar region. 

Treatment. — The importance of correcting even slight poste- 
rior curvatures of the spine which directly interfere with the proper 
expansion of the chest and which when more extreme may 
induce disarrangement or displacement of the internal organs is 
evident. 



DEFORMITIES OF THE SPINE 



227 



The treatment is similar to that of lateral curvature. The 
assumption of the military attitude, with the head erect, the chin 
depressed, the shoulders thrown back, the chest expanded, and 
the abdomen retracted, should be encouraged. And those ex- 
ercises that expand the chest and that strengthen the muscles 
of the upper part of the spine are especially important. (Such 
exercises are illustrated by Figs. 105, 106, 113, 114, 119, 120 
129, 135, 137, 139, 162, and 163.) If the range of vertical ex- 
tension of the arms is limited, this restriction must be overcome 




Exercises for the correction of 



curvatures of the spine. (Hoffa.) 



before the deformity of the spine can be permanently improved. 
In well-marked cases the patient should be encouraged to read 
or study in the prone posture; in this attitude, in which the trunk 
must be supported upon the elbows and the head held backward, 
there is necessarily an involuntary correction of the deformity. 
In certain instances a light spinal brace or corset may be employed 
during the hours when the passive attitude must be assumed 



228 



ORTHOPEDIC SURGERY 



(Fig. 164). Shoulder braces, so-called, are useless, because 
the lumbar lordosis is increased when the shoulders are drawn 
backward. Clothing should not restrict the movements of the 
arms or trunk, and as little weight as possible should be suspended 
from the shoulders. In the more extreme cases, in which the 
kyphosis is of long duration and rigid, forcible correction after 
the Calot method may be indicated as a preliminary treatment. 
Fixed support, preferably the plaster corset, is employed until the 
patient has become accustomed to the new attitude. Afterward 
treatment by exercise and posture is continued as in the ordinary 




Tempered steel uprights for round shoulders. (Bradford and Lovett.) 

type. Whenever a patient is under treatment for deformity of 
the trunk the attempt should be made to restore the proper rela- 
tion of the body and limbs, and thus to restore the general sym- 
metry of the body. 

Lordosis. — Lordosis, or an abnormal hollo wness of the back, 
is far less common than kyphosis. It is not a simple postural 
deformity, but it is usually secondary to disease or deformity 
either of the spine or of the adjoining members. For example, 
lordosis may be induced by flexion contraction of the thighs; 
it is a symptom of congenital displacement of the hips; it is 
sometimes a result of certain forms of nervous disease, in which, 



CONGENITAL ELEVATION OF THE SCAPULA 229 

because of muscular weakness, the body is swayed backward to 
retain the balance, as in the muscular dystrophies. Lordosis 
in the lumbar region may be a compensation for a kyphosis in 
the upper segment. It is caused directly by spondylolisthesis. 
It may be a congenital deformity, and it is said to be a peculiarity 
of contortionists. 

Treatment. — As lordosis is usually a secondary deformity its 
treatment would be included in the treatment of its causes. In 
some instances the discomfort which is usually present when the 
deformity is well-marked may be relieved by a proper corset 
sufficiently strong to support the back. 

Congenital Elevation of the Scapula. 

Synonym.— Sprengel's deformity. 

Sprengei's deformity is a congenital elevation of the scapula 
above the level of its fellow, an elevation accompanied in most 













in 




I 


' 



Congenital elevation of the right scapular; with the arm elevated the scapular is in contact 
with the occiput, as is indicated by the deep fold; age of the patient three months. 

instances by rotation, so that its lower angle is brought nearer to 
the spine while its upper border projecting above the clavicle 
has in several instances been mistaken for an exostosis (Fig. 165). 
The cervical muscles passing to the scapula are shortened and 
changed in direction. Thus, its mobility is lessened and the range 
of vertical extension of the arm is restricted. The deformity 
may be combined with torticollis or with cervical ribs or defective 
formation of the spine for example, absence of vertebrae or rhachis- 
chisis. In many instances there is an accompanying^lateral curva- 



230 



ORTHOPEDIC SURGERY 



ture of the spine, the convexity being usually toward the deformed 
side. And not infrequently the posterior border of the scapula is 
attached to one or more of the lower cervical vertebrae by a bony 
growth. Ninety-nine cases have been collected from literature re- 
cently by Zesas. 1 Forty-seven were of the right side, thirty-six of 




Congenital elevation of the scapular of a moderate degree in adolescence. 

the left, and in eleven both scapulae were elevated. Of eighty- 
two cases forty-eight were in males. 

The deformity was first described by Eulenburg 2 but in more 
detail by Sprengel, 3 who reported four cases in children from one to 
seven years of age. 

Etiology.— The etiology is doubtful, but in many instances it 
appears to be the result of a constrained position of the foetus. 
In two of Sprengel's cases, seen soon after birth, the arm appeared 
to have been fixed behind the back of the child. 

It is of interest to note that, according to Chievitz, the upper 
limb is in its origin a cervical appendage, retaining an elevated 



i Zeits. f. Orth. Chir., Band xv., Heft 1, 1905. 
s Archiv f. klin. Chir., 1868. 



Centralbl. f. Chir., 1895. 



CERVICAL BIBS 231 

position during foetal life, and that interference with its descent 
by constraint or otherwise may explain the etiology. 

Congenital elevation of the scapula may be simulated by the 
distortion and muscular atrophy resulting from birth palsy, or 
even by certain cases of rotary lateral curvature in which the 
scapula is elevated and prominent. 

Treatment. — If the case is seen in childhood and if the contrac- 
tion of the vertebras capula muscles is extreme, the shortened 
tissues may be divided by open incision as in torticollis, and if 
the scapula is joined to the spine the bony process should be re- 
moved. In older subjects no treatment other than that for the 
lateral curvature is, as a rule, indicated. 



The Absence of Vertebrae. 

Absence of vertebrae is usually associated with rhachischisis. 
Several cases, however, have come under my observation in 
which there was absence of vertebrae without other malforma- 
tion. In two of the cases the deficiency was in the cervical 
region, in the others in the lumbar. The noticeable shortness 
of the affected section of the spine was the only symptom. 

Cervical Ribs. 

Cervical ribs are not uncommon. Forty-six cases are reported 
by Riesman. 1 The rib may be complete, articulating with the 
sternum, or incomplete, connected by ligament with the sternum 
or first rib, or it may be simply an elongated transverse process. 
In most instances the anomaly is bilateral. 

If the ribs are complete the neck appears wide and short and 
the projecting ribs may be felt as bony prominences (Fig. 167). 

The subject is of surgical interest because a number of cases 
have been reported in which pressure, on the nerves and blood- 
vessels induced pain and even paresis of the arm and feeble 
circulation. Such symptoms, as a rule, do not appear until ado- 
lescence or adult life. The treatment is resection of that portion 
of the rib that causes pressure. 

Absence of Ribs. — Absence or defective formation of ribs is 
uncommon. In such cases there is usually defective formation of 
the corresponding muscles, and lateral curvature of the spine is 
often present. 

1 Univ. of Penna. Bulletin, March, 1904. _ _ 



232 ORTHOPEDIC SURGERY 

Defective Formation of the Pectoral Muscles.— Several 
instances in which one or both of the pectoral muscles were 
defective or absent have been observed at the Hospital for 
Ruptured and Crippled. The malformation in these cases caused 
no direct symptoms. 1 

Absence or Defect of the Clavicle. — Thirty-eight cases of de- 
fective formation of the clavicle on one or both sides are recorded. 2 
In most instances a portion of the sternal extremity is present. 
The defect appears to cause but slight inconvenience. 



Deformities of the Chest. 

The Flat Chest.— The so-called flat chest is an accompani- 
ment of the round back (Fig. 159). In most instances the chest is 
not actually flattened in the sense that its anteroposterior diameter 
is diminished. It appears flatter because the shoulders and 
scapulae are displaced forward. 

Woods Hutchinson has called attention to the fact that the 
so-called flat chest is usually a round chest, in the sense that it is 
actually deeper than the normal, a persistence of the foetal type. 
He suggests that such persistence may be one of the causes of 
so-called round shoulders, the round clu-st affording no adequate 
support for the scapulae. 

Hutchinson 3 has presented an index showing the relative depth 
of the chest at different ages, illustrating the progress from the 
keel chest of the lower orders to the bellows-shape of the adult 
human form. This index is found by dividing the anteroposterior 
diameter at the nipples by the transverse diameter at the same 
level; hence the lower the index, the longer and flatter, more 
bellows-like the chest. 

Foetal index 103 

Infantile index ......... 87 

Child '.hi 

Adult 71' 

Treatment. — The treatment of the so-called flat chest is similar 
to that of the round shoulders, with which it is often combined — 
thai is, by exercises conducted with the special object of improv- 
ing the strength of the muscles of the back and increasing the 
expansion of the upper part of the chest. The importance of 

; Martirene, Revue d'Orthopedie, May, 1903. 

- Klar, Zeits. f. Orth. Chir., Bd- xv.. Heft 2, 1906. 

8 Journal American Medical Association, September 11, J ^07. 



DEFORMITIES OF THE CHEST 



233 



correcting the deformity, which interferes with the proper expan- 
sion of the lungs and thus predisposes to disease, should be evident. 



Pigeon Chest. Synonym. — Pectus carinatum. 
The pigeon, or keel-shaped, chest resembles the quadrupedal 
type in that the anteroposterior is increased at the expense of the 



234 



OR THOPEDIC SURGERY 



lateral diameter. The sternum is thrust forward and downward 
like the keel of a boat, the lateral compression being most marked 
at the junction of the ribs and the cartilages. This deformity is 
almost always acquired (Fig. 168); it is usually an effect of rha- 
chitis, and it is described under that heading. It may be in- 
duced by obstruction of respiration caused by enlarged tonsils 
and the like, if this is present at an early age. It may be a second- 

Fig. 168 




General rhachitic distortions and pigeon chest. 



arv effect of the sinking forward and downward of the upper 
half of the trunk, as in Pott's disease of the middle of the spine. 
Treatment. — The treatment of secondary deformity would be 
included in the treatment of the affection of which it is the result. 
Manipulation, massage, and breathing exercises may be employed 
in the treatment of simple pigeon chest. The tendency is toward 
spontaneous cure; it is rarely seen in adult life. 



DEFORMITIES OF THE CHEST 235 

The Funnel Chest. Synonym.— Pectus excavatum. 

This deformity (Fig. 169) is the reverse of the pigeon chest. 
The sternum is depressed and the lateral diameter of the thorax 
is correspondingly increased. The milder types of the affection 
in which there are one or more depressions or hollows in the 
sternum are common. The extreme form, in which the entire 




Pectus excavatum. This patient has ocular torticollis also. 

sternum is depressed, is rare. It is practically always a congenital 
deformity, and it is not susceptible to direct treatment. 

Minor Deformities of the Chest.— As has been stated, distor- 
tions of the chest secondary to deformity of the spine are often 
discovered before the original cause is suspected. And the impor- 
tance of the various minor irregularities of the chest or in the 
direction of the ribs when once discovered is often exaggerated. 



236 ORTHOPEDIC SURGERY 

They are usually the result of preceding rhachitis. The increase 
of the capacity of the chest by appropriate exercises aids in the 
correction of asymmetry. 

Scapular Crepitus. 

Loud creaking or grating sounds induced by the movement of 
the scapula on the thorax sometimes appear without apparent 
cause or are developed by exercises during the treatment of lat- 
eral curvature. The causes are apparently bony irregularities, 
bursa?, and the like. Twenty-two cases are reported by Kuttner. 1 

Acquired Luxation or Subluxation of the Clavicle. 

Partial displacement of the sternal end of the clavicle is not 
particularly uncommon. In some instances it is caused by injury; 
in others no cause can be assigned. Most often there appears to 
be a laxity of the capsular ligament that allows a displacement 
during certain movements of the arm. The displacement is 
readily reduced, but the weakness and insecurity may cause dis- 
comfort and disability. 

Treatment. — In some instances the displacement may be pre- 
vented by the pressure of a pad and truss spring, attached behind 
to the corset or braces and passing over the shoulder close to the 
neck. Such an appliance is especially useful if the displacement 
occurs at certain times only, as in dressing the hair, playing on 
the violin, etc. Cures are reported as the result of the injection 
of alcohol into the joint from time to time, and Wolff 2 has oper- 
ated with success as follows: The joint is opened by a straight 
incision. A fragment of bone is detached from the clavicle above 
and a similar one from the sternum; these, still adherent to the 
periosteum, are overlapped in front of the joint and the capsule 
is then sutured. As a rule the affection is not of particular 
importance. 

Asymmetrical Development. 

In normal individuals there is often a slight difference between 
the two halves of the body, and, as is well known, inequality 
in the length of the legs is not at all uncommon. Inequality of 

1 Deutsch. med. Wochenschrift, June 23, 1904. 

2 Centralbl. f. Chir., November 30, 1893. 



ASYMMETRICAL DEVELOPMENT 



237 



the two halves of the body may be congenital, and it may be 
evident at birth, but usually it does not attract attention until 
adolescence. In many instances this inequality is a slight 
atrophy, the result of a cerebral hemiplegia of early childhood. 
In other instances the inequality may be due to congenital hyper- 




Hypertrophy of the right forearm and hand, due to congenital nsevus. 



trophy that may affect the entire limb. In such cases the 
enlargement may be due to an abnormal amount of normal tissue, 
but in most instances the hypertrophy, which becomes more 
marked with the growth of the child, is caused by an abnormal 
blood supply, a form of congenital nsevus (Fig. 170). 



238 



ORTHOPEDIC SURGERY 



Table of Weight, Height, and Ciecumference of the Chest in 
Childhood. (Boas.) 



Kilos. 


Height. 








Inches. 


Cm. 


3.43 


20.6 


52.5 


3.26 


20.5 


52.2 


7.26 


25.4 


64.8 


7.03 


25.0 


64.6 


9.29 


29.0 


73.8 


8.84 


28.7 


73.2 


10.35 


30.0 


76.3 


9 98 


29.7 


75.6 


12.02 


32.5 


82.8 


11.56 


32.5 


82.8 


14.14 


35.0 


89.1 


13.60 


35.0 


89.1 


15.87 


38 


96.7 


15.41 


38.0 


96.7 


18.71 


41.7 


106 8 


18.06 


414 


105.3 


20.48 


44.1 


112.0 


19.87 


43.6 


110.9 


22.44 


46.2 


117.4 


21.78 


45.9 


116.7 


24.70 


4S.2 


122.3 


24.01 


48.0 


122.1 


26.58 


50.1 


127.2 


26.10 


49.6 


126.0 


30.22 


52.2 


132.6 


29.07 


51.8 


131.5 


32.83 


54.0 


137.2 


31.87 


53.8 


136.6 


36.21 


55.8 


141.7 


36.90 


57.1 


145.2 


40.04 


58.2 


147.7 


41.36 


58.7 


119.2 


45.03 


61.0 


155.1 


45.50 


60.3 


158 2 


50.26 


63.0 


159.9 


49.17 


61.4 


155.9 



Inches. Cm. 



Birth i Female 

6months JFemlle 

!y ear ' {Kale 

!8 months { Female 

9 vPflim > Male 

2 years 1 Female 

a „ f Male 

6 1 Female 

, a J Male 

* 1 Female 

= « f Male 

1 Female 

fi ,. f Male 

1 Female 

7 ., f Male 

\ Female 

o „ f Male 

° I Female 

q « f Male 

3 1 Female 

10 ,, j Male 

1U 1 Female 

,, ., f Male 

11 • • t Female 

19 <, ] Male 

1 1 Female 

1Q .. f Male 

16 1 Female 

u ., f Male 

l * 1 Female 

15 « ( Male 

10 t Female 



7.55 
7.16 
16.0 
15.5 
20.5 
19.8 
22.8 
22.0 
26.5 
25.5 
31.2 
300 
35.0 
34.0 
41.2 
39.8 
45.1 
43.8 
49.5 
48.0 
54.5 
52.9 
60.0 
57.5 
66.6 
64.1 
72.4 
70.3 
79.8 
81.4 
88.3 
91.2 
99.3 
10U.3 
110.08 
108.04 



13.4 
13.0 
16.5 
16.1 
18.0 
17.4 
18.5 
18.0 
19.0 
18.5 
20.1 
19.8 
20.7 
20.5 
21.5 
21.0 
23.2 
22.8 
23.7 
23.3 
24.4 
23.8 
25.1 
24.5 
25.8 
24.7 
26.4 
25.8 
27.0 
26.8 
27.7 
28.0 
28.8 
29.2 
30.0 
30.3 



34.2 
33.2 
42.0 
41.0 
45.9 
44 4 
47.1 
45.9 
48.4 
47.0 
51.1 
50.5 
52.8 
52.2 
54.8 
53.5 
59.1 
58.3 



62.2 
60.8 
63.9 
62.5 
65.6 
63.0 
67.2 
65.8 
68.8 
68.3 
70.6 
71.3 
73.3 
74.1 



The Functional Pathogenesis of Deformity. 

Wolff's Law. — "Every change in the form and function of 
the bones or of their function alone is followed by certain definite 
changes in their internal architecture, and equally definite second- 
ary alternations of their external conformation, in accordance with 
mathematical laws." 

Mention has been made, and will be made again from time to 
time, of the adaptation of members or parts to abnormal condi- 
tions, and of the transformation of deformed parts to the normal 
when the improper relations of weight and strain have been 
removed. This theory or law of functional adaptation has been 
established by Professor Julius Wolff, of Berlin, who has shown 
its application to the bones, the most unyielding structures of the 
body. He first called attention to the fact that the shape of a 
bone is the effect of function. It is the effect of function in that 
if the work required of it had been different its shape would have 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY 239 

been different. This function has shaped not only the external 
contour but the internal structure as well. If a bone is broken, 
for example, the neck of the femur, and deformity results, the 
internal architecture is no longer suitable for the new conditions 
of weight and strain, and immediately a rearrangement begins, 
which finally transforms the internal structure, not only in the 
neighborhood of the injury, but in the extremity of the bone also, 
to adapt the deformed part as well as may be to the work that is 
now demanded of it. 

Fig. 171 




Dislocated femur, showing the atrophy and rearrangement of the internal structure 
as compared with the normal (Fig. 172). (Freiberg.) 

The normal bone is braced most thoroughly, and is most re- 
sistant at the points where most work is required of it. If the 
weight and strain are for any reason transferred to another part, 
its structure becomes hypertrophied there, and correspondingly 
weakened at the point from which the strain has been removed. 
With this change in the internal structure a change in the external 
contour keeps pace. For, according to this theory, "the external 
contour represents mathematically simply the last curve uniting the 
ends of the various trajectories which make up the internal structure." 



240 ORTHOPEDIC SURGERY 

For the further exposition of this theory I quote from Frei- 
berg's 1 review and abstract of Wolff's 2 final article. 

"In showing that improper static demands made upon an 
extremity resulted in the formation of new masses of bone upon 
the surface of the bone of this extremity, or that they produce 
the disappearance (atrophy) of bone masses according to the nature 
and degree of these disturbances in static requirements, it has at 




Normal femur from same subject. (Freiberg.) 

once been shown in what manner deformities have their origin. 
For these transformations on the surface of bone are nothing 
other than 'deformities' in the wider or narrower sense of the 
term. 

"Taking genu valgum or habitual scoliosis as an example, the 
development of a deformity in the narrow sense is thus explained. 
In the beginning of either of these conditions the shape of the 

1 Annals of Surgery, July, 1897; and American Journal of the Medical Sciences, December, 
1902. 

a Die Lehre von der functionellen Pathogenese der Deformitilten, Archiv f. kliuische 
Chirurgie, Bd. liii., H. 4. 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY 241 

bones is perfectly normal. As the result of excessive fatigue in 
their too weak muscles the patients are frequently assuming a 
faulty position of limb or body; they seek to control excessive 
excursions of their joints by the interference of the articular 
structures themselves instead of by muscular activity. The 
result is a continual alteration in the static requirements made 
upon the bones and the internal architecture; internal and ex- 
ternal configuration of the bones accommodate themselves to the 
new conditions. Since, according to this reasoning, deformities 
are nothing less than the result of these transformations which 
the external form of bones or joints undergo in accommo- 
dating itself to faulty demands made upon them, it must be 




Section of femoral head of a paralytic idiot, aged thirty-five years, showing the extreme 
atrophy caused by disuse. (R. T. Taylor.) 

self-evident that these deformities are to be considered patho- 
logical only in the sense that hypertrophy of the cardiac muscle 
in valvular insufficiency is pathological. That which is really 
pathological is only the altered static requirements, the abnormal 
mechanical function. Far from being pathological the deformity 
is the only suitable or even possible form by means of which 
bone or joint can withstand the altered forces bearing upon it; it 
is nature's way of securing the greatest possible service and strength, 
under the new conditions, with the use of the least possible amount 
of material. 

"The pathogenesis of deformities is, therefore, functional. Genu 
valgum, for instance, represents only the functional accommo- 
dation of femur, tibia, and knee-joint to the improper static 

16 



242 ORTHOPEDIC SURGERY 

demands made by the outward deviation of the leg. Just so are 
the shapes of the bones in club-foot the expressions of similar 
functional accommodation to an inward rotation of the foot, or 
even, sometimes, an inward turning of the whole lower extremity. 
The faulty position of an extremity under these circumstances is 
to be regarded rather as a cause of the deformity than as an effect. 
This faulty position must always occupy a place intermediate 
between the remote causes of deformity (hereditary predisposi- 
tion, habit, muscular weakness, external conditions causing 
pressure or narrowing space of growth), and the anatomical 
results which these various remote causes bring about. 

"When the altered demands upon an extremity do not occur 
spontaneously, as in the above instances, but, on the other hand, 
result from a primary disturbance in the shape of the bones, due 
to trauma or bone disease with consequent softening or destruc- 
tion of tissue, there is added to this a secondary change in the 
external configuration of the bones, and there is thus caused a 
'deformity in the broad sense of the word.' The difference 
between the two varieties of deformity, therefore, lies only in the 
addition of a second etiological factor (the trauma, etc.) to the 
deformity in the broad sense. Both varieties have it in common 
that the shape of the bones and joints of the deformed part repre- 
sents nothing else than the expression of a functional accommo- 
dation to the faulty static demands made upon it. 

"As a second example by means of which to explain the cor- 
rectness of the doctrine of functional pathogenesis the author has 
selected scoliosis. In the first chapter the author showed in 
detail that the altered conditions in the length and height of the 
transverse processes of scoliotic vertebrae as well as corresponding 
conditions in the ribs of the scoliotic thorax are so evident as not 
possibly to escape notice, and that they can be explained in no 
other way than as functional accommodation to the circumstances 
of space, changed and brought about by the continual, faulty, 
and cramped position of the thorax; this is as true of the convex 
as of the concave side of the vertebral column, to which the trans- 
verse processes and ribs in question belong. It must be manifest 
that changed relations of one part of the skeleton to any other 
part of the skeleton (as far as space conditions are concerned) 
necessarily bring about changes in the mechanical demands made 
upon this part, and, therefore, changes in the directions and values 
of the pressure, tension, and shearing strains of each and every 
point in this part of the skeleton. The conclusion thus drawn, 



THE FUNCTIONAL PATHOGENESIS OF DEFORMITY 243 

that accommodation to space means the same as accommodation 
to function, is of greatest importance to the general doctrine of 
functional accommodation. 

"The origin of the wedge-shape of the scoliotic vertebra now 
comes under discussion. It is assumed by the majority of writers 
that an abnormal softness of the bones is present in scoliosis by 
means of which a faulty position can model the bodies of the 
vertebrae as it does in the case of rhachitic disease of the bone, or 
as is really the case with the intervertebral disks in cases of 'habit- 
ual scoliosis/ While unsupported by any pathologico-anatomical 
investigations, it is allowed possible, or even probable, that such 
softness of the bones plays a role in many cases of scoliosis. It 
is certain, however, that this is by no means always the case; 
as evidenced by the development of scoliosis after empyema in 
adults, and the great exaggeration in adult life of very slight 
scolioses originating during youth. It is concluded, on the con- 
trary, that the vertebra may acquire its scoliotic wedge-shape 
entirely independent of the pressure of the superincumbent weight. 
Furthermore, in the absence of any abnormal softness of the bones, 
the body of a vertebra may lose height on the concave side and 
gain the same on the convex side through the 'tropic stimulus 
of function' purely; being simply an accommodation to the dimin- 
ished space on the concave side and increased room at the con- 
vexity and the change of mechanical conditions consequent 
thereupon. 

"This simple and natural conception of the circumstances con- 
cerning the scoliotic wedge must obtain credence, especially since 
the old view, corresponding to the 'pressure theory/ has been 
long ago disproved by Hoffa and Nicoladoni — namely, that the 
concave side of the wedge is the seat of atrophy, and that this 
atrophy accounts for the loss in height of the vertebral body on 
this side." 

The importance of Wolff's theory, which shows how deformity 
may be acquired and how it may be avoided, is very evident. 
It is of equal importance in indicating the principles of treatment. 
For example, from the anatomical description of a club foot the 
distortion might appear to be irremediable, but on this theory 
one feels assured that if the foot can be fixed for a sufficient time 
in the overcorrected position, the influence of the new static con- 
ditions will immediately induce a transformation, not only in soft 
parts, but in the bones as well, that will finally effect a complete 
and absolute cure. So, also, the correction of a distorted bone 



244 OR TEOPEDIG SURGERY 

by operative means is at best but imperfect; if, however, the 
static conditions have been changed, nature will in time recon- 
struct the entire bone so perfectly that in a few years practically 
no trace of the former distortion, either in contour or internal 
structure, will be evident. Scoliosis might be cured as perfectly 
as the club foot or the bow-leg, were it possible to restore as easily 
the normal conditions of weight and strain. 

Atrophy of Bone. 

The writings of Wolff have emphasized the fact that bone is a 
living tissue very readily affected by changing conditions, and that 
atrophy or hypertrophy of bone may be local or general, accord- 
ing to the change in functional use of the affected part. 

Since the Roentgen ray has come into general use particular 
attention has been called to the atrophy of the internal structure 
of bone that follows lessened use or disuse, or from what is called 
trophic disturbance of nutrition from any cause. For example, 
after fracture or joint disease, or nervous affections, or even 
slight injuries of the nature of sprains, eccentric atrophy is ap- 
parent — that is, weakening of the lamellae of the spongy por- 
tion and decrease in thickness of the compact substance of the 
bone. 

This atrophy is not only rapid, but it may be widespread, as 
proved by the investigations of Sudeck, 1 who could distinguish 
atrophy of the bones of the foot within six weeks after fracture of 
the leg. Atrophy of bone is especially rapid as a result of acute 
affections of the joints, corresponding in this to the atrophy of 
the muscles under similar conditions. In the ar-ray negative 
such atrophy is indicated by a loss of clearnsss of outline which 
is replaced by a peculiar blur, resembling closely the infiltration 
due to disease. 

Weigel has called attention to cases in which general trophic 
disturbance of an entire extremity was induced by iujnry of a 
joint. This disturbance was indicated by congestion, coldness and 
persistent weakness of the extremity, and it was always accom- 
panied by marked and general atrophy of the bones. These 
nutritive changes explain the delay in recovery after apparently 
slight injury or disease of a joint or other tissue. The treatment 
therefore, should be stimulative, and functional use of the weak 
part should be encouraged as soon as possible. 2 

1 Fortsc. auf dem Gebiets. der Rontgenstrahlen, Bd. iii„ H. 6. 
s Mally et Richon, Revue de Chir., vols. xxiv. and xxv. 



HYPERTROPHY OF BONE 245 

After long-continued disuse the bones may be extremely fragile. 
This fact must be borne in mind when one attempts to correct 
deformity caused by paralysis, by rheumatoid arthritis, and the 
like. 

Hypertrophy of Bone. 

This is usually due to disease. It may be general, as in osteitis 
deformans. It may affect corresponding bones, as in syphilitic 
enlargement of the tibiae, or it may be limited to a single bone. 
Of this a familiar example is chronic osteomyelitis, which may 
induce thickening and elongation of the affected bone sometimes 
to the extent of two or more inches. 



CHAPTER V. 

TUBERCULOUS DISEASE OF THE BONES AND JOINTS 

Etiology. — Three factors are recognized in the etiology of 
tuberculous disease: the infectious element (the tubercle bacillus), 
the general predisposition of the patient, and the local condition 
that favors the reception and the growth of the bacilli. 

Predisposition. — The predisposition, both general and local, 
is spoken of as lessened vital resistance. A general predisposi- 
tion to disease may be inherited or it may be acquired. Thus, 
a history of tuberculosis in the immediate family of the patient 
is supposed to imply a lessened resistance to this form of dis- 
ease. In a certain proportion, perhaps 25 per cent., of the 
cases this inherited predisposition is very direct and positive, 
but in the larger number the family history is as indefinite as 
in a similar class of patients under treatment for any other form 
of ailment. The acquired predisposition is of more direct 
importance, since it would include the lowering of the vitality 
due to improper food and improper hygienic surroundings of 
every variety, together with the greater liability to depressing 
diseases and the more constant exposure to tuberculous infection 
that such conditions imply. Thus, tuberculous disease of the 
bones, as well as of other parts, is more common among the poor 
of cities than among the more favored classes. 

Mode of Infection. — The tubercle bacilli may be introduced to 
the body by inhalation and find their way to the bronchial glands, 
or by the mouth and set up disease in the mesenteric glands, 
or, after infection of the nasal passages or neighboring parts, 
secondary disease of the cervical lymphatics may cause the so- 
called scrofulous glands of the heck. 

Latent Tuberculosis. — It may be assumed that disease of the 
bronchial and mesenteric glands is not uncommon in individuals 
of apparently perfect health, since it is often discovered at au- 
topsies in those who have died from other causes. For example 
in 2713 autopsies on children who died of acute infectious diseases 
reported by Ganghofner tuberculous tissues were found in 502 
or about 20 per cent. This form of glandular disease is called 
latent tuberculosis, and it usually precedes a local outbreak 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 247 

in the bone or elsewhere. In many instances the disease 
may remain latent and finally disappear, or it may persist, 
and from time to time free bacilli or bits of infected tissue may 
escape into the blood current; by it they are deposited in other 
parts, where, under favoring conditions, local disease may be 
set up. Depression of the vitality from any cause may be sup- 
posed to favor the progress of the glandular disease, which 
may lead to a dissemination of the infectious elements, and 
at the same time it may lessen the resistance of other tissues 
that may be exposed to the infection. This accounts for the 
well-known influence of certain diseases, such as measles and 
whooping-cough, not only in predisposing to local tuberculous 
disease, but in favoring its progress when it is already established. 
It is possible, also, that the bacilli that have found their way 
into the blood current more directly, as, for example, through 
wound infection, may set up primary disease of a bone or joint. 
In fact, it is stated by Kcenig 1 that in fourteen of sixty-seven 
autopsies on subjects who had suffered from tuberculous dis- 
ease of the bones and joints, no other foci were found in the 
body. In other instances the source of infection may be pre- 
existent disease of the lungs or of other internal organs. 

In 769 autopsies oh children under twelve years of age, at the 
Hospital for Children, Great Ormond Street, London, reported 
by G. F. Still, 2 269 presented tuberculous lesions. Of these, 117 
were less than two years of age. 

The apparent channels of infection, as evidenced by the appear- 
ance of the glandular lesions, were as follows: 

Respiratory: 

Lungs 105 

Probably lungs 33 

Ear 9 

Probably ear 6 

153 = 57 per cent. 
Alimentary: 

Intestines 53 

Probably intestines 10 

63 = 23.4 per cent. 
Other cases: 

Bones or joints 5 

Fauces 2 

Uncertain 46 

53 

Northrup and Bovaird 3 have made similar observations at the 
New York Foundling Hospital: 

1 Deutsche Chir., 1900, L. 2Sa, S. 157. " British Medical Journal. August 19, 1899. 

3 Northrup, New York Med. Journal, February 21, 1891. Bovaird, Ibid., July 1, 1899 



248 OB THOPEBIC SUBQEBY 

Infection by respiratory tract 148 

Infection by mesenteric lymph nodes 3 

Indeterminate 48 

199 

In sixteen instances the process was confined to the bronchial 
glands, and in no instance were these glands found to be free from 
disease. 

Bovaird 1 has collected the reported autopsies on tuberculous 
children with reference to primary intestinal infection, and has 
called attention to the fact that the English observations are not 
in accord with others: 

. . . Primary intestinal 

Autopsies. digease 

German ...... 236 9 = 4 per cent. 

French 128 

English 748 136 = 18 

American ..... 369 5 = 1 " 

1481 150 

Haushalter, 2 in 78 autopsies upon children dying from acute 
miliary tuberculosis, found in all but 4 disease of the tracheo- 
bronchial glands. In 44 this disease was the most ancient focus 
in the body. 

Local Predisposition. — The local conditions that favor the 
growth of the tubercle bacilli may be induced by injury. Slight 
injury sufficient to cause, for example, a hemorrhage into the 
substance of the cancellous tissue induces a local congestion dur- 
ing the process of repair that provides the proper soil for the 
growth of the bacilli when they are deposited in its neighborhood. 
This has been proved experimentally by Krause, and it is sup- 
ported by clinical evidence. The great preponderance of disease 
in the lower over that of the upper extremities in childhood may 
be cited as evidence of the influence of injury in the causation of 
disease. 

In 513 of 3398 cases of tuberculosis of the bones and joints 
reported by Hildebrand, 3 Koenig, Mikulicz, and Bruns injury 
seemed to be a direct predisposing cause of the local disease 
(16.5 per cent.). A much higher percentage than this has been 
assigned by certain writers, but the exact relation of traumatism 
to disease can only be conjectured. For example, Voss 4 in 577 
cases treated at Rostock found injury stated as the exciting cause 
in more than 20 per cent. Yet on further investigation in but 7 
per cent, could its influence be clearly established. 5 

1 Archives of Pediatrics, December, 1901. 2 Archiv. de Med. des Enfants, March, 1902. 
3 Deutsche Chir., 1902, L. 13, S. 168. 4 Zeit. f. Chir., 1904, No. 16. 

6 The literature of the subject may be found in the Archiv. f. Orthop. Mechanicotherflr 
pie u. Unfall Chir., Bd. iv., H. 4, 1900, Deutschlander. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 249 

The primary disease is almost always in the newly formed 
bone about an epiphyseal cartilage. This tissue is vulnerable; 
it is, therefore, more exposed to direct injury; it is subjected, 
also, to the strain of motion at the neighboring joint, and as the 
circulation is here more active the bacilli are more often deposited 
in this situation. 

The vulnerability of growing bone accounts also for the relative 
frequency of bone disease in childhood, as compared with adult 
life. Injury not only causes a local predisposition to disease, but 
it favors its progress when it is once established. 

Distribution of the Disease. — In 13,308 cases of tuberculous 
disease of the bones and joints treated at the Hospital for Rup- 
tured and Crippled the distribution was, in order of frequency, as 
follows : 

Vertebra 5,662 = 42.5 per cent. 

Hip-joint 4,048 = 30.5 

Other joints 3,598 = 27.0 

13,308 

In a total of 3561 cases treated at the Hospital for Ruptured 
and Crippled and at the Vanderbilt Clinic during a period of 
five years the distribution was as follows: 

Vertebrae 1432 = 40.2 per cent. 

Hip-joint 1123 = 31.5 

Knee-joint 699 = 19.6 

Ankle-joint 196 = 5.5 

Elbow-joint 62 "| 

Shoulder- joint 42 \ = 3.1 

Wrist-joint 



32 ) 

"I" 



3561 

Trunk 1432 = 40 . 2 per cent. 

Lower extremities 2018 = 56.6 

Upper " Ill = 3.1 " 

The correspondence between these two tables of statistics is 
striking, and the number of cases is so large that the proportions 
may be accepted as approximately correct as applied to the dis- 
tribution of the disease in childhood. 

At the Boston Children's Hospital in a period of twenty-five 
years, 1869-1893, 3820 cases were treated. 1 The distribution was 
as follows: 

VertebriB 1964 = 51.4 per cent. 

Hip 1402 = 36.7 " 

Ankle 300 = 7.8 

Knee 104 = 2.7 " 

Wrist 20- 

Shoulder 15 J- = 1.3 

Elbow 15 



Report of the Boston Children's Hospital. 



250 ORTHOPEDIC SURGERY 

Trunk 1964 = 51 . 4 per cent. 

Lower extremities 1806 = 47.2 " 

Upper " 50 = 1.3 

Side Affected.— Disease of the joints is slightly more common 
on the right than on the left side of the body. At the Hospital 
for Ruptured and Crippled the proportions in the cases treated 
during a recent period of ten years are as follows: 

Hip, right 53 per cent. 

Knee, right 55 

Ankle, right 50 

Shoulder, right 64 

Elbow, right 60 

It has been stated that one of the explanations of the great 
preponderance of the disease of the lower over the upper extremity 
is the greater liability to injury. The same explanation has been 
advanced to account for the greater frequency of disease on the 
right side, which is more marked in the upper than in the lower 
extremity, because the right arm is more liable to overwork as 
well as to injury. 

Sex. — Tuberculous disease of the joints is somewhat more 
common among males than females. 

Of 3822 cases of Pott's disease treated at the Hospital for 
Ruptured and Crippled, 2037, or 53 per cent., were in males. 

Of 3307 cases of disease of the hip-joint treated at the same 
institution, 1731, or 52.3 per cent., were in males. 

Of 1218 cases of disease of knee-joint, combined statistics 
of Koenig and Gibney, 703, or 57.6 per cent., were in males. 

Age. — In 5461 cases of tuberculous disease treated at the Hos- 
pital for Ruptured and Crippled, about seven-eighths of the 
patients were less than fourteen years of age. 

(vertebra;, 87.7 per cent, 

hip, 88.2 

other joints, 71.7 

( vertebrae, 7.7 per cent. 

Between 14 and 21 years of age . . . -j hip, 9.2 

I other joints, 10.7 

(vertebrae, 4.5 per rent, 

hip, 2.5 

other joints, 17. 5 1 

Of 1259 cases of Pott's disease treated recently at the same 
institution, 1075, or 85 per cent, of the patients, were in the first 
decade; 50 per cent, were three to five years of age, inclusive, at 
the inception of the disease. 

In 1000 cases of disease of the hip-joint the ages of the patients 
correspond closely to these; 87.2 per cent, were in the first 

1 Knight. Orthopedia. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 251 

decade and 45.2 per cent, were from three to five years of age, 
inclusive. 

In 1000 cases of disease of the knee-joint, 75 per cent, were in 
the first decade and 40 per cent, were from three to five years, 
inclusive. 

In 339 cases of the ankle-joint, 70 per cent, were in the first 
decade and but 35 per cent, were included within the three years. 

The distribution of the disease and its relative frequency at the 
different ages is shown by Alfer's table of statistics from Tren- 
delenburg's clinic at Bonn. 1 





0-5 15-10 


10-15 


15-20 20-25 25-30 

! 1 


30-35 


35-40 


40-45 


45-50 50-55 


55-60 


1 
60-65 65-70 


Total 


Vertebrae 


89 


59 


32 


23 


9 


10 


3 


6 


3 


1 


4 











239 


Hip 


h« 


h9 


43 


46 


9 


11 


6 


1) 


4 


1 


1 


3 








241 


KDee 


47 


52 


47 


37 


20 


11 


23 


11 


11 


3 


2 


8 


6 


3 


281 


Ankle 


f) 


9 


10 


5 


2 


1 


1 


3 


?, 





3 





2 





43 


Shoulder 





2 


2 


6 


3 


5 


3 


1 


1 


2 


2 


1 








28 


Elbow 


7 


14 


14 


21 


12 


9 


6 


5 


9 


8 


5 


2 


2 





114 


Wrist 


1 





1 


5 








3 


1 


3 


2 


1 


3 





20 


Total 


207 


195 


148 


139 


60 


47 


42 


29 


31 


18 


19 


15 


13 


3 


966 



This table illustrates the well-known fact that disease of the 
upper extremity, relatively infrequent at all ages, is proportion- 
ately far more common in adult life than is disease of the lower 
extremity. Of the joints of the lower extremity, the knee and 
the ankle are proportionately more often diseased in later life 
than is the hip. 

Pathology. — When the bacilli are deposited in a part, the irri- 
tation of their toxins causes a proliferation of the fixed cells 
which lie in direct contact with the germs, and about these a ring 
of leukocytes forms. The bacilli, the epithelioid cells including 
often one or more giant cells, together with the surrounding leu- 
kocytes, constitute the visible tubercle of bone, a minute grayish 
speck in the cancellous structure. The central cells about the 
bacilli, increasing in number, deprived of nourishment and poisoned 
by the toxins, die and are disintegrated to granular material, 
"caseate," and the tubercle changes to a yellow color; but the 
bacilli, multiplying and escaping, form new tubercles about the 
original focus, which coalesce as the area of the disease enlarges. 
Meanwhile, the surrounding tissue becomes congested, as the 
result of the irritation, and the fixed cells become organized, 
or partly organized, into a feeble, ill-nourished form of granula- 
tion tissue, representing the effort of the part to shut out and to 



Beit, zur klin. Chir., Bd. viii., H. 2. 



252 OB THOPEDIC SUBGEBY 

expel the foreign substances formed by the disease. Or, if this 
local resistance is effective, the cells become actually organized into 
firm granulations which surround and destroy the germs, and then 
are further transformed into scar tissue. But in most instances 
either because the irritation is insufficient or because of the defi- 
cient vitality of the part, the granulations are feeble and unstable, 
and they in turn becoming infected by the multiplying bacilli 
serve only to extend the area of the disease. This granulation 
tissue, before and after the stage of infection, absorbs and destroys 
the bone. If the progress of the disease is slow, the cancellous 
structure is completely absorbed or is represented only by bone 
sand, but if the disease infiltrates the bone more rapidly it may 
destroy its vitality while its structure is still retained, and a 
sequestrum is formed. Such sequestra, consisting of rounded, 
yellow, crumbling masses of cancellous structure, of the size of 
a pea or larger, are especially common in epiphyseal disease 
of childhood. In rare instances wedge-shaped sequestra are 
found with the base at the periphery of the epiphysis. These 
are supposed to be caused by the lodging of an infected embolus 
in a terminal vessel, thus cutting off the blood supply. 

By the formation of new tubercles at the periphery, and by 
the caseation of material in the centre of the diseased area, a 
cavity in the bone is formed, containing the debris of the granu- 
lation tissue, often sequestra of larger or smaller size, and a 
variable amount of fluid, made up of serum and leukocytes, that 
has exuded from the surrounding granulations. The walls of 
this cavity are formed by tissues in which the disease is active; 
the inner layer containing the tubercles in the various stages of 
formation and decay, the outer, composed of feeble, ill-nourished, 
granulation tissue as yet not infected, and beyond this the softened 
and infiltrated bone. If the disease has ceased to progress in 
any direction the granulations contain more bloodvessels, they 
are of firmer consistency and more perfectly organized, and the 
substance of the bone is harder, showing the evidence of repair. 

One termination of epiphyseal disease is by enclosure of the 
focus by resistant granulations, behind which the bone solidifies 
and shuts in the disease, or, in favorable cases in which its area 
is small, completely absorbing and replacing it by scar tissue. 

Extra-articular Disease. — As a rule, the tendency of the process 
is to expand and to force an opening through the cortex of the 
bone to the exterior. In certain cases this opening may form 
outside the capsule of the joint, and through it the products of 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 253 

the disease may be discharged into the overlying tissues, forming 
a tuberculous abscess. Here, the same process of infection and 
extension of the area of disease continues, but more rapidly than 
when it was confined within the bone. The surfaces of the muscles 
and fascia are infected, and are covered with an abscess mem- 
brane of violet or grayish-yellow color, made up of tuberculous 
tissue and masses of fibrin, lying upon and loosely attached to 
the outer inflammatory or healthy granulations. 

The tuberculous fluid is usually of a thin consistency, composed 
of serous exudation, leukocytes, fibrin, masses of degenerated 
tissue, and fragments of bone or bone sand. It is commonly of 
a whitish color, occasionally reddish from mixture with blood, 
and, in the later stages, yellow and serous-like. The abscess 
enlarges in the direction of least resistance, and in most instances 
finally perforates the skin by one or more openings through which 
its contents are discharged. Or, its boundaries may cease to 
extend, its contents may be absorbed, adhesions may form 
between its walls, and a spontaneous cure is effected. Extra- 
articular disease, without ultimate involvement of the joint, is 
unusual. It is more common at those joints like the knee, elbow, 
and ankle, in which the bones are superficial; it is very uncom- 
mon at the hip-joint, and it is practically impossible in disease 
of the spine. 

Perforation of the Joint. — Usually the tuberculous process within 
the epiphysis, enlarging its area, comes into contact with cartilage, 
and, perforating this, finds its way into the joint. While the 
disease is still confined within the bone, the tissues within the 
joint are involved in a sympathetic irritation or inflammation. 
The synovial membrane becomes congested and hypertrophied; 
the synovial fluid is increased and changed in quality; fibrin 
forms and is deposited upon the cartilage and upon the lining 
membrane of the capsule. It is stated by Koenig that the or- 
ganization of these fibrinous deposits upon the cartilage plays 
an important part in its destruction, even when actual tuberculous 
disease is absent. As a result of the sympathetic inflammation 
within the joint, adhesions may form which may limit the area of 
the tuberculous disease and retard its progress after perforation has 
taken place. This process is similar to the inflammatory changes in 
the pleura caused by underlying tuberculous disease of the lung. 

When the disease comes in contact with the cartilage it disin- 
tegrates; the tuberculous granulations breaking through and 
spreading over its surface destroy it in piecemeal, or, advancing 



254 OR THOPEDTC S UR GER Y 

beneath it, separate it from the bone in large, necrotic fragments. 
The synovial membrane becomes thickened and infiltrated, 
numerous tubercles appear upon its surface, which undergo the 
secondary changes that have been described, and the joint be- 
comes, practically speaking, an abscess cavity. The surfaces 
of the bones are disintegrated by the disease, and the destruction 
is hastened by the pressure and friction due to muscular spasm 
and to functional use. The thickened capsule, distended by the 
fluid and solid products of the disease, is usually perforated, and 
a secondary abscess, communicating with it, is formed in the sur- 
rounding tissues. As results of the disease, secondary changes 
appear in the neighboring parts. The irritation of the periosteum 
if the disease is of a quiescent type, may induce the formation of 
irregular layers of bone or osteophytes about the joint. A new 
formation of connective tissue proceeding from the layer of granu- 
lations that surround the disease may extend to the muscles and 
tendon sheaths, binding them together, and causing limitation of 
motion. The newly formed connective tissue may be very vas- 
cular and irregular in formation, and intermixed with it may be 
masses of gelatinous or myxomatous tissue. This, according to 
Krause, is due to the venous stasis and (Edematous infiltration 
caused by the pressure of the capsular contents and extracapsular 
proliferation of granulation tissue. These changes in the appear- 
ance and in the consistency of the tissues about the joint are char- 
acteristic of the so-called white swelling. 

Tuberculous disease is most common in the neighborhood of 
the epiphyseal cartilage, thus involving the joints. Occasionally, 
however, it may appear primarily in a diaphyses. A familiar 
example is central disease of the phalanges — "spina ventosa" — a 
slow infiltrating form of disease accompanied often by sinus 
formation. Distortion and atrophy follow. In this form of 
disease the infection is often multiple. 

Other Forms of Tuberculous Disease of Joints. — All of the 
German writers describe forms of primary synovial disease, its 
frequency varying from 16 to 35 per cent, of the cases. It is 
more common in adult life than in childhood, and at the knee 
■than at other joints. Nichols, 1 on the other hand, states that he 
has examined 120 tuberculous joints, and has found in every 
instance one or more foci in the bone that apparently preceded 
the disease in the joint. This is certainly not in accord with 
clinical experience, for one must recognize a form of disease in 

1 Transactions American Orthopedic Association, vol. xi. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 255 

which the symptoms differ from the ordinary osteal type. It 
begins as a chronic synovitis, although the tissues are more thick- 
ened and infiltrated than in simple synovitis, and the muscular 
atrophy is more marked. Reflex spasm and limitation of motion 
are slight, and the symptoms are rather discomfort and fatigue 
after exertion than actual pain. After many months or years, 
when it may be assumed the bones are involved, the characteristic 
symptoms of tuberculous disease appear. In one form of syno- 
vial disease the amount of effused fluid is large, and it is clear 
and serous-like in character — hydrops tuberculosus ; but usually 
it is cloudy, and it may be purulent in character. 

As has been stated, Koenig lays stress upon the important part 
played by fibrin in the changes that take place within a joint. 
Fibrin deposited from the effused fluid forms in successive layers 
upon the cartilage. Into this fibrin vessels grow from the hy- 
pertrophied and infected synovial membrane, destroying the 
cartilage together with the underlying bone. If the synovial 
disease is primary the bone is destroyed superficially, but if it is 
secondary to synovitis disease within the epiphysis it is usually 
more extensive. Synovial tuberculosis is essentially a chronic 
affection and is often mistaken for simple or so-called rheumatic 
synovitis. 

Arborescent Synovial Tuberculosis. — In this form the interior of 
the joint is covered with villous proliferations of the synovial 
membrane. It is not a distinct disease, but is an irritative hyper- 
trophy that is present in syphilitic and rheumatic as well as in 
tuberculous joints. Its especial interest lies in the fact that the 
hypertrophied synovial growths may cause mechanical interfer- 
ence with the function of the joint. 

Lipoma Arborescens. — Arborescent villous proliferations are 
formed of adipose and fibrous tissue covered with a layer of round 
cells. The hypertrophied masses which project into the joint are 
often of large size, attached to the synovial membrane by a 
smaller pedicle. They are single or multiple, and vary in color 
from yellow to deep red. They may be of a soft or firm consist- 
ency. In this form of disease, as in that described in the pre- 
ceding section, there is usually pain, limitation of motion; often 
the swollen joint is irregular in outline; the hypertrophied syno- 
vial prolongations are sometimes apparent on palpation. 1 The 
exact diagnosis is usually made only after an exploratory incision, 
and in such an event the removal of the larger growths would 
be indicated. The outcome depends, of course, upon the cause, 



256 ORTHOPEDIC SUBGEB Y 

the hypertrophy depending usually on an underlying tuberculous, 
syphilitic, or so-called rheumatoid disease. In the instances in 
which the hypertrophied tissue is in itself the cause of the dis- 
ability, cure may follow its removal. 

Rice Bodies. — Rice bodies are numerous small, grayish-white 
bodies resembling cucumber seeds that are found in certain forms 
of synovial disease, and particularly in tuberculosis of tendon 
sheaths. They are formed of fragments detached from the pro- 
liferating synovial membrane and possibly of simple fibrin, which, 
under the influence of pressure and attrition in the movements of 
the joint or of the tendon, assume the characteristic shape and 
appearance. These bodies, within a tendon sheath or joint, cause 
a peculiar creaking, perceptible to the touch when the part is 
moved. 




Lipoma arborescent ( Paint ei'andlErving.) 

Dry Caries. Caries Sicca. — In this form of disease, which is 
apparently primarily synovial, there Is but little formation of 
fluid, and there Ls but little tendency toward cheesy degeneration 
of the tuberculous products. The infected granulations destroy 
the bone without forming sequestra, and usually without sup- 
puration. This form more often occurs at the shoulder-joint, 
and it is characterized by marked limitation of motion, extreme 
atrophy of the surrounding parts, and sometimes by forward 
displacement of the partly destroyed head of the humerus that 
may be mistaken for a primary dislocation. 

1 Painter and Erving, Boston Med. and Surg. Journal, March 19, 1903. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 257 

Septic Infection. — When a tuberculous abscess has opened spon- 
taneously, or when it has been incised, infection with pyogenic 
germs is common, and it occasionally occurs before a communi- 
cation with the exterior has been established. 

After such infection the surrounding tissues become infiltrated, 
reddened, and sensitive to pressure. The discharge is greatly in- 
creased in quantity and changed in quality. The local pain and 
discomfort are aggravated; if the joint is involved the destruction 
of the bone goes on with increased rapidity, and the constitutional 
effects of pyogenic infection appear. If the area of the abscess is 
small and if the drainage is efficient, this accident is of slight impor- 
tance, and it may even exercise a beneficial effect in stimulating 
the circulation and dissolving the effused material about a joint. 
But if the abscess has burrowed widely into surrounding tissues 
and if it communicates with an important joint it is a dangerous 
complication; in fact, the greatest direct danger of tuberculous 
joint disease. Persistent suppuration exhausts the patient, and 
by lessening the vital resistance it favors the local advance of the 
tuberculous disease and its general dissemination. It is in this 
class of cases that amyloid degeneration of the internal organs is 
common, induced not by tuberculous disease, but by the secondary 
infection and its consequences. 

Repair. — Repair in tuberculous disease may be accomplished 
by the absorption, ejection, or enclosure of the disease. The 
process of repair usually accompanies the advance of the destruc- 
tive process, and examples of the three methods of cure may be 
found in a single joint. 

The curative agent is the granulation tissue which forms about 
the area of disease, and which, finally becoming sufficiently organ- 
ized to resist the infection of the bacilli, solidifies into fibrous 
tissue. In those cases in which the disease is not absorbed or 
completely thrown off in the abscess formation, but is enclosed, it 
becomes quiescent. In such cases traumatism, when, for example, 
the surrounding adhesions are broken down in the attempt to 
rectify deformity or to overcome anchylosis, may cause local 
recurrence of the disease. 

Prognosis. — The prognosis will be considered more particularly 
in the sections on disease of special parts. The danger to life is 
direct and indirect, and this varies greatly with the part that is 
affected and with the age of the patient. 

In disease of the spine the direct danger to life is greater than 
in joint disease, because of its situation, since it may involve the 

17 



258 ORTHOPEDIC SURGERY 

spinal cord or extend to the important organs in the neighborhood. 
Abscess may in rare instances, merely by its size and situation, 
endanger life, and when infected it is far more dangerous because 
of the difficulty in providing efficient drainage. The influence of 
deformity and its effect in compressing the internal organs and thus 
interfering with the vital functions is another more remote element 
of danger in disease in this situation. 

The danger to life from disease of the joints is in proportion to 
importance. In rare instances it may extend from the epiphysis 
to the shaft of a bone and set up an extensive osteomyelitis; or 
the patient may be weakened by the suffering caused by active 
disease, but, as has been stated, the most direct and constant 
danger is from prolonged suppuration that follows septic infection. 
Danger from this source is much greater at the hip-joint than at 
the ankle or elbow, for example, because of the greater difficulty 
in preventing the burrowing of pus when infection has occurred. 

The indirect danger of tuberculous disease is its dissemination 
to more important organs. But it by no means follows that the 
disease of the joint is the source of the general infection. For, as 
has been stated, it may be inferred that nearly every patient with 
joint disease has also disease of the lymphatic glands, and in a 
certain proportion of the cases there may be active disease of other 
important organs as well. Tuberculosis of the lungs, for example, 
is often present in the adult before the local outbreak in the joint 
appears, and it is in great degree because of this liability to disease 
of the lungs that the prognosis of joint disease becomes progres- 
sively worse with the age of the patient. 

This point is illustrated by the statistics of Koenig and Bruns 
on the final results of disease of the knee- and hip-joints, to which 
attention will be called again in the special sections. In Koenig's 
cases of disease of the knee-joint the influence of age upon the 
death-rate is illustrated by the following table: 

Less than 15 years of age 20 per cent. 

From 16 to 30 years 24 

" 30 to 40 " 44 

More than 40 " 60 

In Brims' statistics the death-rate was of patients in the first 
decade, 36 per cent.; in the second decade, 44 per cent.; older 
than this, 72 per cent. 

The cure of latent tuberculosis in the lymph nodes as well as 
of active disease of the lungs or bones depends upon the vital 
resistance of the patient. This vital resistance is lessened by 
pain, by confinement and lack of exercise. It is directly impaired 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 259 

by the exhausting suppuration and by the poisoning of the toxins 
incidental to septic infection. Under these conditions the local 
disease advances and a general dissemination is more probable. 
This accounts for the fact that death from general tuberculous 
infection is far more common in this class than when suppura- 
tion has been slight or absent. This point is again illustrated 
by the statistics referred to. The death-rate in the cases of dis- 
ease at the knee without abscess was 25 per cent., with abscess 
46 per cent. Death-rate in cases of disease at the hip with ab- 
scess 52 per cent., without abscess 23 per cent. 

It is probable that tuberculosis may be disseminated by opera- 
tion upon tuberculous joints, although the evidence upon this 
point is vague and conflicting. Gibney, contrasting two equal 
periods of thirteen years of service at the Hospital for Ruptured 
and Crippled, in the first of which no operations were performed 
on tuberculous subjects, states that in his opinion the deaths from 
this source have been proportionately no greater during the period 
of active surgical intervention than before. And an investiga- 
tion of the causes of deaths among the patients treated at the 
New York Orthopedic Dispensary and Hospital during a period 
of twenty years showed that at least 25 per cent, of these were 
due to tuberculous meningitis. 1 During this period there had 
been, practically speaking, no operative intervention, yet the 
proportion of deaths from this cause is certainly as great as in 
any statistics that have been reported. It would appear, then, 
that the danger of dissemination is not sufficient to deter one 
from performing any operation that seems to be indicated by the 
character of the local disease or by the general condition of the 
patient. 

Diagnosis. — Diagnosis is considered at length in the sections 
on diseases of the special joints. The tuberculin test, although of 
some importance from the negative standpoint, is of no partic- 
ular value as establishing a diagnosis of joint disease, for the 
reason that tuberculous disease of the lymph glands is so com- 
mon even among those whose joints are free from disease. For 
the same reason it is valueless as a test of practical cure. This is 
illustrated by the investigations of Frazier and Biggs 2 of patients 
clinically cured of. local tuberculosis, some by operative means. 
In 78 per cent, of these a positive reaction to tuberculin was ob- 
tained. In some instances however, a local reaction may indicate 

1 Personal communication from Dr. David Bovaird. 

2 University Medical Magazine, February, 1901. 



260 ORTHOPEDIC SURGERY 

foci of disease whose presence would not otherwise have been 
suspected. 

Tinker, who has reported a series of four hundred tests from 
Johns Hopkins Hospital, states that healthy individuals react if the 
dose is sufficiently large. One, therefore, begins with small injec- 
tions, from 1 to 3 milligrams of Koch's old tuberculin. This may 
be increased to 9 milligrams, a reaction to less than this amount 
being practically positive if the temperature of the patient taken 
at intervals of two hours for at least eighteen hours has been 
normal. The reaction appears in from six to eight hours. 

The x-ray is often of value in demonstrating the effects 
of disease, and in certain instances it may indicate its exact 
locality and extent. As a means of early diagnosis of joint dis- 
ease in young subjects, however, it is of little importance as 
compared to the physical signs, because of the non-development 
of the bony structure of the epiphysis, which alone appears in 
the negative. 

Treatment. — From what has been stated of the causes of dis- 
ease it follows that the general treatment should include, if possible, 
a change in the hygienic conditions, relief from the danger of 
further infection, pure air, and proper food. These are as essen- 
tial in the treatment of tuberculosis of the bones as of other parts. 

The importance of the constitutional treatment of tuberculous 
disease, more particularly the proper environment in which the 
greater part of the day and even the night may be passed in the 
open air, can hardly be exaggerated. 

As far as the cure of local disease is concerned, no treatment 
can be as effective as the prompt and thorough removal of the 
focus of disease, while it is yet limited in extent, and before the 
joint has become involved. This is practicable, however, in but 
a small proportion of the cases in childhood, because it is usually 
impossible to locate the disease accurately and impossible to 
remove it without sacrificing much of the healthy bone upon 
which the future usefulness of the part depends. At one time 
early operation, even complete excision of the joint, was justified 
on the plea that the disease might thus be eradicated. But now 
that it is known that in nearly all cases other tuberculous foci 
exist in the body, and as the functional results after these early 
operations are far inferior to those attained under conservative 
treatment, early excisions are limited to the adolescent or adult 
cases. For in this class growth has been attained and the econ- 
omic conditions require that the period of disability should be as 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 261 

short as possible. In this class, also, early exploratory opera- 
tions are often indicated, sometimes for the purpose of establish- 
ing the diagnosis, and if the disease is of the synovial type the 
removal of projecting folds of hypertrophied tissue and the direct 
application of irritants, for example, of pure carbolic acid, may 
be of service. Brace treatment is conducted with the aim of 
relieving the part of function — that is to say, from strain and 
injury. Functional use of a diseased joint delays natural repair, 
since it causes pain and thus reduces the reparative force, while it 
stimulates the disease and increases its destructive action. The 
details of treatment will be described in the consideration of disease 
of special joints. 

Treatment by Drugs. — The administration of drugs occupies a 
very subordinate place in treatment, since it is not believed that 
any drug exercises a direct action upon the local disease in the 
bone. 

Cod-liver oil, the hypo phosphites, the various preparations of 
iron or other tonics may be given at certain times with benefit, 
but the continuous administration of medicine during the years 
that are required to complete a cure is, of course, out of the 
question. 

Local Applications. Iodoform. — Iodoform is supposed to exer- 
cise a direct germicidal action and also to stimulate the forma- 
tion of the granulations that cast off or absorb the tuberculous 
products and then become transformed into fibrous tissue. At 
one time direct injection of the remedy into the bones was 
advocated, but this has now been abandoned, and its use is prac- 
tically limited to the treatment of tuberculous abscesses and 
certain forms of synovial tuberculosis. Iodoform is ordinarily 
employed in an emulsion with glycerin or oil, 10 c.c. of 10 per 
cent, mixture being injected at intervals of two or more weeks. 
Several deaths from iodoform poisoning have been reported, but 
injections of this quantity of the drug are apparently free from 
danger. 

Iodoform Filling for Bone Cavities. — V. Mosetig-Moorhof 1 
uses a mass made up of finely powdered iodoform 60 parts, 
spermaceti and oil of sesamum 20 parts each. The mixture, 
which becomes fluid at 50° C, is throughly stirred before using. 
The cavity in the bone having been made thoroughly dry is filled 
with the fluid, which solidifies as the temperature is lowered. The 

1 Deutsche Zeitsc. f. Chir., vol. lxxi., No. 5. 



262 ORTHOPEDIC SURGERY 

wound is then closed. The filling is slowly absorbed, its object 
being to preserve the contour of the bone. In a series of 220 
cases reported by this author no local disturbance followed the 
procedure. 

Carbolic Acid. — Carbolic acid in dilute solutions was at one 
time injected in tuberculous cavities, but its use has been gen- 
erally discontinued because of the danger of poisoning. Recently 
Phelps has advocated the use of pure carbolic acid in the treatment 
of tuberculous abscesses and sinuses. This is injected into the 
fistula? or into the abscess cavity, which has been opened, and 
is allowed to remain for about a minute, when it is neutralized 
by copious injections of alcohol, after which the part is thoroughly 
cleansed by salt solution. Carbolic acid doubtless acts as a 
caustic, destroying the infected granulations and stimulating the 
reparative processes. Other remedies of this class, for example 
tincture of iodine, chloride of zinc, actual cautery and the like, 
are also used, and in certain cases with benefit. In the treatment 
of tuberculous ulcerations ichthyol, balsam of Peru, and iodoform 
are among the drugs employed. Balsam of Peru dissolved in 
castor oil of a strength of about 10 per cent., as suggested by 
Van Arsdale, is a very satisfactory application. 

X-ray Treatment. — The x-ray as a local treatment appears to 
act as a stimulant of the reparative processes. It is of especial 
value as an adjunct in the cases in which the tissues about the 
joint are infiltrated and traversed by discharging sinuses. The 
exposure of the diseased tissues to the direct rays of the sun is 
certainly a harmless treatment, and it should be applied if occasion 
offers. 

ACTIVE AND PASSIVE CONGESTION IN THE TREATMENT 
OF AFFECTIONS OF THE JOINTS. 

Bier's treatment of tuberculous joint disease was suggested by 
the observation of Rokitansky, that phthisis was uncommon in indi- 
viduals suffering from disease of the heart when the mechanical 
obstruction was sufficient to cause venous congestion of the lungs. 

Passive or venous congestion of a joint is attained by con- 
stricting the limb with several circular turns of a rubber bandage 
above the affected joint sufficiently to interfere with the return of 
the venous blood, but not with the arterial supply. 

The congestion is localized by bandaging the limb firmly with 
flannel or other somewhat elastic material up to the lower margin 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 2G3 

of the joint. When properly applied the joint becomes swollen 
and dark red in color. The local temperature is raised. This 
is what Bier calls hot congestion, as distinct from oedema (cold 
congestion), that would result if the rubber bandage were applied 
so tight as to constrict the arteries. Passive congestion should 





The alcohol lamp and chimney. Used 
for active congestion. (Bier.) 

not cause or increase pain. If 
it has this effect it is improperly 
applied or is unsuitable for the 
case (Fig. 175). 

The application should be 
limited to periods of one to 
three hours daily according to 

The application of passive congestion: A, \\\q effects. 1 
the alternate point for the application of the 
bandage, in order to avoid atrophy from 
continuous pressure. B, the rubber bandage. 
(Bier.) 



1. It increases the formation 
hypertrophy of the bones. 

2. It has a bactericidal action 
notably tuberculosis. 



The action of the venous or 
passive congestion is, according 
to Bier, as follows : 
of fibrous tissue and induces 



in infectious joint disease, 



Bier, Hyperamie als Heilmittel, Leipzig, 1905. 



264 ORTHOPEDIC SURGERY 

3. It exercises an absorptive effect on the effused products of 
disease and on new formations that check joint motion. 

4. It relieves pain and lessens the activity of progressive joint 
disease. 

The most important indication for passive congestion is in the 
treatment of tuberculous disease. 

If applied for disease of the wrist-joint it is unnecessary to 
bandage the fingers, as the finger-joints are usually stiff either 
from disuse or from adhesions about the tendons — a condition 
for which treatment by venous congestion is indicated. 

Passive congestion for tuberculous joint disease should be sub- 
ordinated to protective treatment, although this is not the opinion 
of Bier, who favors motion rather than fixation of the diseased 
joint. It may be continued indefinitely according to its effect. 
As a rule, pain is lessened by the treatment and muscular spasm 
decreases. This latter effect is in part, at least, explained by the 
constriction of the muscles. 

Abscess formation or appearance at least is apparently 
favored by the congestion. This may be treated by aspiration 
or incision and by the injection of the iodoform emulsion if 
desirable. 

Passive congestion is employed also for the treatment of chronic 
disability following injury, for chronic disease, such as rheu- 
matoid arthritis or other affection attended by infiltration of 
tissues and by deficient circulation. In this class of cases the 
local congestion may be combined with massage. 

The treatment of acute infectious processes of joints and other 
tissues by passive congestion has now come into general use. 
Bardenheuer is one of its most enthusiastic advocates. 1 

Active Congestion. — Active congestion is induced by the local 
use of heat, ordinarily hot dry air. 

In its simplest form the apparatus consists of an alcohol lamp 
provided with a long metal chimney reaching to a box of wood 
or metal, into which the limb is inserted through openings at 
either end. The box has one or more small openings for the 
escape of air and moisture. The limb is usually wrapped in 
sheet wadding, and is particularly well protected from the parts 
of the box which may come in contact with the skin. The heat 
is then applied, usually to about 250° or 300° F., for from thirty 
minutes to an hour daily. The degree of heat is indicated by 

1 Deutschen f. Chir., XXXV. Kongress, 1906. 



TUBERCULOUS DISEASE OF THE BONES AND JOINTS 265 

a projecting thermometer, and it is regulated by the comfort 
of the patient and by the observation of its effects. 

Bier prefers simple boxes of wood of various shapes suitable 
for the different parts of the body, lined with packing cloth soaked 
in a solution of water glass. He considers these as efficacious 
as the complicated and expensive appliances, and at the command 
of all who desire to employ the treatment (Fig. 162). 

The effect of the heat is to induce arterial instead of venous 
hyperemia, and to cause profuse local and general perspiration. 
Active hyperemia is not suitable for the treatment of acute or 




The application of the hot-air box for inducing active congestion. The box. C, the 
thermometer. A, a metal pipe projecting from the box, into which the chimney of the 
lamp is placed. B, lamp chimney. (After Bier.) 

progressive joint disease. It exercises a dissolving and absorb- 
ing action on effused material and on the tissues of new forma- 
tion causing limitation of motion within a joint. It increases 
local nutrition and it relieves pain. It is especially indicated in 
the treatment of local disability after injury, chronic effusions 
into joints, rheumatoid arthritis, chronic rheumatism, and the 
like in which the circulation is deficient. 

As a rule, the application of local heat should be supplemented 
by massage. The profuse general perspiration that is induced 
by it is a contraindication in weak individuals. 



CHAPTER VI. 

NON-TUBERCULOUS DISEASES OF THE JOINTS. 

Syphilitic Diseases of the Joints. 

Tn early infancy the characteristic syphilitic disease of the 
bones is a form of osteochondritis. Painful, sensitive swellings 
appear at the epiphyseal junctions, either as small, hard tumors 
or as general enlargements, resembling those of rhachitis (Fig. 
178). As a rule, several epiphyses are involved, more often 
those at the distal extremities of the bones of the lower limbs, 
and in these cases the pain and discomfort may induce an appear- 
ance of helplessness of the part called pseudoparalysis (Parrot). 

In osteochondritis there is a multiplication and irregularity of 
the cartilage cells of the ossifying layer and premature calcifica- 
tion. As a result, the circulation is insufficient and necrosis of 
a part of the cartilage may follow, which, acting as a foreign 
body, sets up inflammatory changes in the adjoining parts. The 
process is shown by a zone of hard, dry, yellow substance in the 
ossifying layer, adjoining which is an inflammation of the tissues 
of the newly formed bone, which is in part replaced by granu- 
lation tissue. If the disease is progressive, ulceration and sup- 
puration may follow; the cartilage may be destroyed, and the 
epiphysis may be separated, causing deformity and cessation of 
growth. The neighboring joint is usually involved in the dis- 
ease. In the milder cases there is a simple sympathetic synovitis; 
in the advanced class a destructive arthritis. In one case seen 
recently in a child three months of age the symptoms of pain on 
motion combined with slight effusion into several joints were 
present without the epiphyseal enlargement. The affection may 
be distinguished from rhachitis by the accompanying evidences of 
inherited syphilis, by the irregularity of the epiphyseal involve- 
ments, and by the age of the patient and the absence of the other 
symptoms of rhachitis. 

In the later manifestations of hereditary syphilis, in which the 
bones in the neighborhood of the joint are involved in syphilitic 
osteoperiostitis, the joint may be sympathetically affected or the 



NON-TUBER CULOUS DISEA SES OF THE JOINTS 267 

disease may actually perforate the joint. In this form of disease 
the synovial membrane is usually hypertrophied and it may 
interfere with the function of the joint. The fluid is increased 
in quantity and the affection may resemble synovial tuberculosis. 
A slow, chronic, infiltrating gummatous form of disease appear- 
ing in later childhood may simulate very closely the appearances 
of so-called white swelling. It is more common at the knee, 
but other joints are often affected as well. In other instances 
one or more of the joints may be involved before the enlargement 
of the neighboring bone is apparent, the symptoms being those 

Fig. 178 




Suppurative syphilitic epiphysitis at lower ends of radius and tibia in an infant aged 
one month. The child died shortly after the drawings were made, and the epiphyses were 
found lying loose in purulent cavities. (Tubby.) 



of chronic synovitis. A common manifestation of hereditary 
syphilis is keratitis. In a series of 77 cases in which this was 
present there was involvement of the joints in 56 per cent., the 
knee being most often affected. 1 

In the secondary stage of acquired syphilis pain and swelling 
of the joints, resembling rheumatism, may be present, and in 
tertiary syphilis the joint may be involved in disease of the neigh- 
boring bones, or the joint itself may be primarily implicated. 



Hippel, Munch, med. Woch., No. 31, 1903. 



268 



ORTHOPEDIC SURGERY 



In most instances the joint affections of syphilis are explained 
by the history and by the other signs of syphilitic disease. Spina 
ventosa (Fig. 180), which is classed as one of the evidences of 
syphilis, is far more commonly of tuberculous origin, as is illus- 
trated by the statistics of Karewski, 1 of 157 cases, in which but 
three were due to syphilis. 

Syphilitic disease of the joints is comparatively rare in orthopedic 
clinics as contrasted with those of tuberculous origin. This is as 




Syphilitic osteoperiostitis of the tibiae resembling anterior bow-leg. This is the most 
characteristic manifestation of hereditary syphilis. It induces not only deformity and hy- 
pertrophy, but elongation of the bones as well. 

might be expected, for not only is tuberculosis far more common 
than syphilis, but a very large proportion, according to Fournier, 
77 per cent., of the syphilitic children are stillborn or die 
shortly after birth. Even among those that survive, disease of 
the bones or joints in the form that could be confounded with 



Chir. Krank. des Kindesalters. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 269 

tuberculosis, is uncommon as compared with its other manifesta- 
tions. 

Treatment. — Certain writers consider hereditary syphilis to be 
a very important predisposing cause of tuberculous disease, and be- 

Fig. 180 Fig. 181 





Hereditary syphilitic disease of 
carpus and phalanges. 



Hereditary syphilitic disease of the 
joints. In this case the interior of the 
right knee-joint was lined with hyper- 
trophied folds of synovial membrane. A 
complete cure followed the administration 
of appropriate remedies. 



lieve that many cases classed as tuberculous are in reality syphilitic, 
even if no history or confirmatory signs of syphilis are present. 
There is no reliable evidence to support this view. The possi- 
bility of the syphilitic taint, remote or direct, should be borne in 



270 OB TH OPE DIC SURGERY 

mind, and in all doubtful cases appropriate remedies should be 
employed. 

In general, the treatment of the joint affection would be in- 
cluded in the general treatment of the disease of which it 
is a complication. If the joint is involved in a destructive pro- 
cess apparatus to ensure rest and protection is indicated. The 
removal of irritative disease in the neighborhood of a joint is 
sometimes possible in older subjects, and in this class of cases an 
exploratory incision for inspection of the joint is sometimes advis- 
able (Fig. 181). 

Gonorrhoeal Arthritis. 

Synonym. — Gonorrhoeal rheumatism. 

So-called gonorrhoeal rheumatism is an inflammation of a joint 
caused by the presence of gonococci. It is said to complicate 
from 2 to 5 per cent, of all the cases of gonorrhoea, usually ap- 
pearing in the later stages of that affection, and it is more com- 
mon among those who are in a debilitated condition. 

Distribution. — In about 40 per cent, of the cases it is mon- 
articular and the knee-joint is most often involved. In 375 
cases collected by Finger the distribution was as follows: 1 

Knee 136 Shoulder 24 

Ankle 59 Hip 18 

Wrist 43 Jaw 14 

Finger-joints 35 Other articulations .... 21 

Elbow 25 

375 

Bennecke 2 has tabulated 78 cases recently under treatment. 
The 78 cases occurred in 56 patients, of whom 18 were males, 
38 females. The distribution was as follows: 

Knee 31 Shoulder 4 

Hip 8 Elbow 10 

Ankle 9 Wrist 6 

Other joints of foot 6 Fingers 4 



In 46 cases recorded by Markheim 3 one joint was involved in 
13 cases, two joints in 12, three joints or more in 18. The order 
of frequency was knee, hip, shoulder, wrist, and elbow. 

Symptoms. — The affection is usually of a subacute character. 
The joint becomes swollen and there is discomfort, and particu- 
larly weakness, and stiffness on use. If the infection is more 

1 Taylor, Venereal Diseases, p. 263. 

- Die Gon. Gelenkentziindung nach beob., der Chir. Univ. Klin, in der K. Chariti' zu Ber- 
lin. Hirschwald, Berlin, 1899. 

3 Deutsche Archiv f. klin. Med.. 1902, vol. lxxii., p. 186. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 27] 

severe there may be local heat, pain, and infiltration of the tissues, 
with accompanying muscular spasm. 

In all the forms the infiltration of the subsynovial tissues of 
the capsule and of the superficial tissues is more marked than the 
actual effusion within the joint. The more serious cases are char- 
acterized by a peculiar cedematous, boggy swelling of the tissues, 
and the skin is hot, sensitive, and glazed. There is usually in- 
tense pain on motion of the limb or on jar. After the subsi- 
dence of the acute symptoms the thickening persists, and practical 
anchylosis may result. 

Gronorrhceal arthritis has been divided into three classes accord- 
ing to its symptoms and physical characteristics^ the serous, the 
serofibrinous, the purulent. 

The serous form is, as its name implies, a simple effusion re- 
sembling other forms of subacute synovitis, although it is of a 
more chronic character. 

The serofibrinous variety is the so-called plastic type of inflam- 
mation. In this form fibrin is deposited upon the cartilage and 
it is afterward organized by the growth of vessels into it from the 
synovial membrane, a process which erodes the cartilage upon 
which the granulations rest. The folds of the synovial membrane 
adhere to one another, the capsule is thickened, and ligaments and 
tendons may be involved in the adhesive inflammation. These 
changes within and without the joint may seriously impair its 
function after the cure of the active disease. 

The 'purulent form is uncommon; it is similar in its character- 
istics to suppurative arthritis from other causes. It is attended 
by great local heat, pain, and swelling, and by constitutional 
disturbance. 

In orthopedic clinics gonorrheal arthritis is usually seen is 
its later stages when the acute symptoms have subsided. In 
these cases swelling and pain persist in many instances, and in 
the more severe class motion is limited or the limb may be fixed 
in an attitude of deformity. An obstinate, monarticular painful 
swelling of a joint suggests gonorrhoea, and its presence or absence 
should always be determined, since the effective treatment of the 
primary cause is essential to the cure of the secondary affection 
of the joint. The same statement is true of painful, persistent 
affections of bursse and tendon sheaths, and of obstinate forms of 
weak foot. 

Fuller, of New York, has reported several cases in which cure 
of persistent disease of joints and tendon sheaths followed 



272 ORTHOPEDIC SURGERY 

direct treatment of gonorrhoeal disease in or about the seminal 
vesicles. 

Treatment. — The local treatment of the early stage of this form 
of arthritis is rest and compression, together with hot or cold applica- 
tions, as may seem to be indicated. Ichthyol ointment in a pro- 
portion of about 40 per cent, appears to relieve the pain and to 
stimulate the absorption of the effusion. If the symptoms are 
acute and if there is constitutional disturbance, the joint should 
be aspirated, and if the examination shows the effusion to be sero- 
purulent, it should be treated by incision and drainage. In the 
chronic form, also, when the capsule is distended by the sero- 
fibrinous effusion, incision and removal of the contents is indicated. 

In the latter stages of disease of the ordinary subacute type, 
the treatment is directed to the absorption of the effused material 
within and without the joint, and to the restoration of functional 
activity. The use of hot air, massage, passive congestion, the hot 
and cold douche, static electricity and the like are of service 
in stimulating the circulation. If the limb has become deformed, 
and if it is fixed by adhesions and by contractions, the deformity 
may be corrected by forcible manipulation under anaesthesia. 
And it may be stated that in this class of cases restoration of 
function to a greater or less degree is often accomplished by this 
means. 

If, however, the limb is fixed in the proper position it is well 
to postpone forcible measures until the effect of the massage and 
gentle passive movements have been observed. 

Functional use is the most effective restorative treatment after 
the acute symptoms have subsided. This is made possible by the 
employment of apparatus which limits motion to the degree the 
joint permits without causing discomfort. 

Gonorrhoeal Arthritis in Infancy.— This complication in in- 
fancy is usually a multiple arthritis of a pysemic character. In 
a series of 78 cases of gonorrhoeal infection treated at the Babies 
Hospital 1 there were ten cases of arthritis, six died directly from 
the disease, two died later from exhaustion, and in the two remain- 
ing, recovery seemed improbable. 

Puerperal Arthritis. — This is so similar in its characteristics 
to gonorrhoeal arthritis that a detailed description is unnecessary. 
It may be stated, however, that puerperal arthritis is usually of 
a more severe type than the preceding affection. 

i Kimball, Med. Record, Nov. 14, 1903. 



NON-TUBERCULOUS DISEASES OF TEE JOINTS 273 



Arthritis Complicating Infectious Diseases. 

The joints may be involved in the course of any infectious dis- 
ease. A mild form of arthritis, often involving several joints, 
is common after diphtheria or scarlatina; of this 53 cases have been 
collected by Brunn, 1 and it is occasionally observed as a sequel 
of pneumonia. This form is usually of a more severe type than 
the preceding forms. 

Brade 2 has reported 60 cases of joint involvement in 868 cases of 
scarlatina treated in St. Jacob's Hospital; 56 were of the serous 
type; 4 were of the suppurative form, causing the death of the 
patients. In but 8 of the cases was the arthritis limited to a 
single joint. 

Arthritis following typhoid fever is often of a severe and de- 
structive type. Keen 3 has tabulated 84 cases. In 43 per cent, 
of these the hip-joint was affected and in 40 per cent, sponta- 
neous dislocation occurred. In a case treated recently at the 
Hospital for Ruptured and Crippled there had been a destruc- 
tive arthritis of one hip-joint, spontaneous displacement of the 
femur on the other side, and secondary contractions at the knees 
and ankles, so that the patient was bedridden. 

Treatment. — The treatment in all forms of arthritis compli- 
cating diseases of this class is to place the affected joint at rest, 
to apply heat or cold as may be indicated by the local condition, 
and to prevent the secondary distortions that lead to fixed de- 
formities. The presence of pus is, of course, an indication for 
immediate incision and efficient drainage; thus, in all doubtful 
cases the character of the effusion should be ascertained by 
aspiration. 

Spontaneous dislocation, which is comparatively common when 
the hip-joint is suddenly distended with fluid, is not likely to occur 
unless the limb is flexed and adducted. This attitude should be 
prevented by the use of traction or support. 

The after-treatment has been indicated already. 

Prognosis. — It is evident that the immediate reaction to bac- 
terial infection and the final results will vary with the virulence 
of the infection, the natural resistance of the individual, and of 
the part involved. According to Poynton and Paine 4 the bacteria 

1 Berlin, klin. Woch., No. 27, 1904. 2 Leipzig, 1903. 

3 Surgical Complications and Sequels to Typhoid Fever. 

4 British Medical Journal, November 1, 1902. 

18 



274 ORTHOPEDIC SURGERY 

reach the synovial membrane through the capillaries of the areo- 
lar tissue, beneath the endothelium, which if uninjured serves 
as a barrier to protect the joint cavity. If the joint is not actually 
involved the restriction to motion will depend upon thickening 
of the tissues of the joint and upon disuse of the muscles. In 
such cases the prognosis is good. If, however, the interior of 
the joint is invaded by a process that causes adhesions, and partial 
destruction of the cartilaginous surfaces, anchylosis is likely to 
follow. 

Marsh 1 divides infectious arthritis into four classes: 

1. Simple infiltration of the subsynovial tissues and slight 
synovitis. 

2. Effusion of fluid into the synovial sac— synovitis. 

3. Infiltration of the periarticular tissues — plastic inflamma- 
tion. 

4. General destructive arthritis. In the first and second classes 
complete recovery may be anticipated. In the third class a vary- 
ing degree of functional disability is to be expected. In the last 
it is inevitable. 

Acute Arthritis of Infancy. 

A form of acute suppurative arthritis primarily within the joint 
or more often secondary to disease of the neighboring epiphysis 
is not uncommon in infancy. 

Etiology. — The disease is usually caused by staphylococci, occa- 
sionally by other forms of infection. (See Gonorrhceal Arthritis.) 
In the early weeks of life it may follow infection at the umbilicus 
or other surface lesion. It may be secondary to one of the exan- 
themata or to gonorrhoea, but in many instances the origin is 
not apparent. 

Falls or blows upon the part appear to be predisposing causes. 

Townsend 2 tabulated 73 cases of acute arthritis, 18 of which 
were personal observations. To these I am able to add 12 others, 
making a total of 85 cases. In 64 of these the infection was 
monarticular; in 21 more than one joint was involved. The 
distribution was as follows: 

Hip-joint 45 = 53 per cent. 

Knee-joint 32 = 37 " 

Other joints 8 = 10 

The sex was specified in 61 cases: males, 38; females, 23. It 

1 British Medical Journal, December, 1902. 

2 American Journal of the Medical Sciences, January, 1890. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 275 

is of interest to note that in all reported cases the males out- 
number the females. In 285 cases, including the above and 
others reported by Gonser, Demme, Liicke, Billroth, Schede, and 
Miiller, the proportion was nearly 3 to l. 1 

Symptoms. — If the infection is severe there is immediate local 
heat, redness, swelling and oedema, great pain, and correspond- 
ing constitutional disturbance. But in many instances the local 
and general symptoms are less marked, the child is fretful, and 
the evident discomfort caused by motion at the affected joint is 
mistaken for result of injury or rheumatism. In this class of cases 
the patient is not, as a rule, seen until several weeks after the 
onset of the affection. The joint is then somewhat infiltrated 
and enlarged, motion is painful and restricted, and the general 
appearances are very similar to tuberculous disease. There are 
also, without doubt, even milder forms of synovial infection 
from which recovery is rapid and practically complete. These 
cases are usually classed as monarticular rheumatism. Similar 
symptoms may be induced directly by injury; motion causes pain; 
the limb is flexed and persistent deformity may result unless pro- 
tection is assured. 

Treatment. — The treatment of suppurative arthritis is, of 
course, free incision and efficient drainage. In all cases the joint 
must be fixed, preferably by a light wire splint, during the active 
stage of the disease. An apparatus is usually required to prevent 
deformity or to support the weak limb when the patient begins to 
walk. 

Prognosis. — If the arthritis is a primary disease within the 
joint complete recovery may follow evacuation of the pus, but, 
as a rule, the neighboring epiphyseal junction is diseased, sup- 
puration is prolonged, and a part of the epiphysis is destroyed 
before the disease ccmes to an end; thus, subluxation or dis- 
placement with subsequent deformity and less of growth are the 
usual results of this form of disease. At the hip-joint, for ex- 
ample, the laxity of the ligaments and the upward displacement 
of the femur that follow destruction of the head of the bone cause 
symptoms that in later life are often mistaken for those of con- 
genital dislocation. 

In some of the cases there is, in addition to the arthritis, an 
osteomyelitis of the shafts of one or more of the bones. These 
cases are usually fatal, or, if the patient survives, there is usually 
necrosis of the affected bones and consequently extreme deformity 

1 Gonser, Jahrbuch f. Kinderheilk., July, 1902. 



276 



OR TH OPE DIC SURGERY 



In the cases reported by Townsend the death-rate was, in the 
monarticular form, 18 per cent.; in the multiple form, 73 per 
cent. 

In a total of 122 cases of all varieties tabulated by Hoffmann, 
the death-rate was 46 per cent. In 87 the affection was confined 




Deformities resulting from infectious osteomyelitis. 

to one joint; in the remainder from two to five joints were in- 
volved. 1 

Acute Tuberculous Arthritis. — In early infancy forms of 
acute tuberculous disease, especially at the knee-joint, may simu- 
late closely infectious arthritis. The joint may become swollen, 

1 Medical Bulletin, Washington University, September, 1902. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 277 

hot, and sensitive to pressure, and the onset may be sudden and 
accompanied by constitutional disturbance. Such cases are more 
often observed in the children of mothers suffering from advanced 
disease of the lungs. 

Acute Osteomyelitis. 

Infectious osteomyelitis is most common in adolescence and the 
extremities of the bones in the neighborhood of the epiphyseal 




Tuberculous osteomyelitis localized in the lower extremities of the radius and ulna, demon- 
strated by the x-ray and removed before the wrist-joint was involved. 

cartilages are most often involved. Trendel, from the histories of 
1058 cases in Bruns 1 clinic, states that it is most common in the 
period from the thirteenth to the seventeenth year. In one-half the 
cases the femur was involved; in one-third the tibia. 

The symptoms are local sensitiveness of the bone, pain, and 
constitutional disturbance. The neighboring joint is usually dis- 
tended by a sympathetic synovitis, and the overlying tissues are 
usually infiltrated. The treatment consists in immediate opening 
of the bone at the suspicious point, in order to relieve the tension 

1 Beit. zur. klin. Chir.. Bd. xli. p. 3. 



278 



ORTHOPEDIC SURGERY 



and to establish drainage. In certain instances the joint itself 
may be directly involved in the disease. This may be inferred if 
the symptoms do not subside after the bone has been opened. 
In doubtful cases the joint should be aspirated for the purpose of 
bacteriological examination, but even if pathogenic bacteria are 
present the treatment by incision or otherwise must be decided on 
the clinical symptoms. 

For in cases of this character bacteria are often found not only 
in affected joints, but hi the blood, and in the marrow of the 




Loss of growth following osteomvelitis of the tihia, necessitating removal of part cf 
the shaft. 



unaffected bones also. The investigations of Fraenkel 1 show that 
specific micro-organisms are present in the red marrow of the 
vertebrae, in the ribs and elsewhere in every form of infectious 
disease, and that they may be found here even when they are ab- 
sent in the blood. In the blood, according to Bertelsmann, 2 they 
may be found in about one-third of all cases of surgical infection 
and far more often when bones or joints are involved. In a 



1 Mit. a. d. grenzgebieten d. Med. u. Chir., Bd. xii. 
-' Deutsch. Zeit. f. Chir.. Bd. lxxii. p. 209. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 279 

series of 48 positive results streptococci were found in 68 per 
cent., staphylococci in 30 per cent. 

The prognosis in neglected cases is bad : for example, in 54 cases 
of acute osteomyelitis of the upper extremity of the femur, in all 
but seven of which the joint was involved, the death-rate was 60 
per cent. 1 

Localized osteomyelitis in the neighborhood of a joint may 
simulate tuberculous disease of the joint. The onset of the 
affection is, however, more abrupt, the surrounding tissues are 
infiltrated, and the symptoms are usually more acute than in the 
latter affection. In this class of cases of the subacute type the 
lesions are often multiple, fresh foci appearing at intervals for 
an indefinite time. The treatment of choice when the affection 
is localized is the operative removal of the diseased area, which 
is indicated by local sensitiveness, and which in many instances 
may be demonstrated by the x-ray. One should be as sparing 
of the bone as possible because of the danger of retardation or 
irregularity of growth that almost always follows the loss of 
even a moderate amount of growing tissue The iodoform filling 
of Mosetig-Moorhof, p. 261, may be used with advantage in this 
class of cases. 



Osteoarthritis and Rheumatoid Arthritis. Arthritis 
Deformans. Rheumatic Gout. 

Under these titles are included a group of chronic diseases of 
the joints whose etiology is obscure. At the present time these 
diseases are usually classed as varying manifestations of one 
pathological process, and the titles are usually considered as 
synonymous. 

Clinically, however, the characteristic types differ markedly 
from one another. In one form bone destruction is combined 
with bone formation, and the final result is an irregular solid 
enlargement of the joint, usually combined with distortion of the 
limb. 

It has been suggested by Goldthwait that the term osteo- 
arthritis should be applied to this type. 

The second form resembles somewhat rheumatism in its course 
and distribution. The disease is primarily of the soft parts of 
the joint, the bone is only secondarily and superficially involved, 

1 Gyot, Rev. des Chir., xxiv., Nos. 2 and 4. 



280 



ORTHOPEDIC SURGERY 



and the final result is limited motion or anchylosis without 
enlargement of the joint. This form is sometimes classed as 
atrophic to distinguish it from the former or hypertrophic variety 
of arthritis deformans, but the term rheumatoid arthritis seems 
to be preferable, as indicating that the two varieties of chronic 




Osteoarthritis. The hypertrophy of the extremities of the bones of the terminal phalanges 
(Heberden's nodes) is accompanied by erosion of the cartilage. The second interphalan- 
geal joint of the second finger shows hypertrophy, combined with destruction and lateral 
displacement. (See Fig. 186.) 

joint disease are distinct and do not represent stages of one 
general affection. 

Pathology of Osteoarthritis.— The effects of the disease are 
most noticeable in the cartilage, which becomes fibrillated and 
destroyed in the parts subjected to greatest pressure, while it 
is thickened and heaped up into irregular layers at the periphery, 
as if under the influence of pressure it had been squeezed out 



NON-TUBERCULOUS DISEASES OF THE JOINTS 



281 



from the interior of the joint (Fig. 187). The process is sup- 
posed to consist in a multiplication of the cartilage cells which 
in the free portion of the cartilage escape into the joint, 
while in those parts covered by synovial membrane they 
are retained. When the cartilage disappears the bone, de- 
prived of its natural protection, is worn away, and under the 




Rheumatoid (atrophic) arthritis. Slight superficial erosions of the bones are to be 
seen at several of the joints. Contrast with osteoarthritis. 



influence of pressure and friction it becomes increased in den- 
sity and hardness, "eburnated." Meanwhile the irregular pro- 
jections of cartilage at the periphery become in part ossified, 
and this, together with a formative periostitis of the adjoining bone, 
causes the irregular bony enlargement characteristic of the disease. 
The contour of the bones and their mutual relation to one 



282 ORTHOPEDIC SURGERY 

another are changed. The synovial membrane becomes hyper- 
trophied and its villi, some of which may contain cartilaginous 
nadules, project into the joint in shaggy fringes. These may be 
detached from time to time and may form loose bodies within 
the capsule. The synovial fluid may be greatly increased in quan- 
tity distending the capsule, or, communicating with bursa;, it may 
form cysts, as is sometimes observed at the knee-joint. But more 
commonly the fluid is decreased in amount. The ligaments are 
weakened and destroyed, and the tendons about the joint become 
adherent to their sheaths and to the neighboring tissues. The 
muscles atrophy and become contracted and structurally shortened 
in accommodation to the deformity. 

Etiology of Osteoarthritis.— Little that is positive is known 
of the etiology of osteoarthritis. Two factors are sufficiently 
evident. These are age and injury or overstrain. The wearing 
out of the joint is suggested by the appearances, and, as is well 
known, similar changes in slight degree are not uncommonly 
found in the joints of laborers of middle age. So, also, similar 
changes may follow injury, particularly fracture at the hip-joint. 
Lessened local and general resistance are, of course, predisposing 
causes. In locomotor ataxia, a disease accompanied by loss of 
sensation and by diminished control of movement, the nutrition 
of the joint is lowered and its natural safeguards against injury 
and overwork are removed. Joint disease (Charcot's disease) of 
the character of osteoarthritis in such instances is undoubtedly 
an indirect effect of disease of the nervous apparatus, but it by 
no means follows that such or any disease of the nervous system 
is necessary to explain the lesions of the ordinary form. It may 
be mentioned in this connection that a form of disease of similar 
character is very common among domestic animals in old age. 
It has been suggested, and it is probably true, that defective 
assimilation may be a causative factor in both man and animals. 

Symptoms. — In its typical form osteoarthritis is an affection 
of middle life and of old age. It may be confined to a single 
joint, and in these cases one of the larger joints of the lower ex- 
tremity is more often affected, particularly the hip or knee. As 
a rule, however, several joints are involved to a greater or less 
degree. Its onset is usually insidious, and the progress is slow, 
accompanied by remission of the symptoms. 

These symptoms are usually pain, discomfort in changing from 
one position to another, "creaking" sensations in the affected 
joints, gradually increasing local enlargement, limitation of 



NON-TUBERCULOUS DISEASES OF THE JOINTS 



283 



motion, and distortion of the limb. Typical examples are found 
in the hip-joint (malum coxae senile) and knee, and these are 
described elsewhere. 

Heberden's Nodosities. — Although typical osteoarthritis may 
be confined to one or more of the larger articulations, it is often 
accompanied by enlargement of the joints of the fingers. It 
should be stated, also, that there is a form of osteoarthritis of 
comparatively slight importance in which the disease is confined 
to the joints of the fingers. The bases of one or more of the 




Osteoarthritis, from the Museum of the College of Physicians and Surgeons, New York. 



distal phalanges become enlarged (Heberden's nodosities), and 
the fingers become somewhat stiff and painful, the pathology 
being very similar to that already described. Gradually other 
phalangeal joints become involved until the fingers become de- 
formed and function is somewhat interfered with. The dis- 
ease is slowly progressive, pain lessening as the enlargement 
and stiffness become more apparent. When the disease begins 
in this manner the larger joints are not often implicated. It 
is interesting to note, however, that this form of disease is far 



284 ORTHOPEDIC SURGERY 

more common in women than in men, and it may be accompanied 
by disease of the larger joints of the nature of rheumatoid 
(atrophic) arthritis (Fig. 186). 

Treatment.— In general, this should be directed to the im- 
provement, if possible, of the condition of the patient. The daily 
routine should conform to what the personal experience of the 
patient shows to be that best adapted to the disability. The 
local nutrition may be maintained by massage, electricity, and 
the like. Deformity may be prevented and pain may be relieved 
by regulating the strain to which the weak part is subjected if 
practicable by the use of apparatus. In certain instances opera- 
tive removal of villous proliferations of the synovial membrane or 
of solid projections that interfere with movement may be of ser- 
vice. (See Spondylitis Deformans and Osteoarthritis of the Hip 
and Knee.) 

Rheumatoid or Atrophic Arthritis. 

Rheumatoid arthritis differs from the preceding type in that it is 
rather an affection of childhood and of early adult life than of 
old age. It is more common among females than males. It is 
more acute in its onset, more rapidly progressive, and mDre general 
in its distribution than osteoarthritis. 

In typical osteoarthritis the cartilage is worn away at the centre 
of the joint, heaped up at the periphery and the underlying bone 
is involved at an early stage of the disease. In typical rheumatoid 
arthritis the affection is primarily of the fibrous coverings and of 
the membranes of the joint, and the cartilage is destroyed in the 
later stages by a pannus-like growth from the periphery. There 
is secondary erosion of the cartilage and of the underlying bone 
unaccompanied by the hypertrophy characteristic of the preceding 
disease. In rheumatoid arthritis a spindle-shaped enlargement of 
the finger-joints is common, but the x-ray picture will not show 
irregular bone formation as in typical osteoarthritis (Heberden's 
nodosities), but a normal contour or at most superficial erosions 
of the bones entering into the formation of the joint. The 
second interphalangeal joints are usually involved primarily. 
There is usually flexion contraction, and in many instances general 
deviation of the fingers toward the ulnar side. In younger sub- 
jects, particularly in the class of cases in which the onset of the 
disease is acute, and in which there is considerable effusion, 
there may be subluxation or actual luxation of the phalanges, 



NON-TUBERCULOUS DISEASES OF THE JOINTS 285 

more often at the metacarpal articulations. In such instances 
motion is preserved in the affected joints. 

In typical cases the final result in any joint is either anchylosis 
or limited motion accompanied by flexion deformity. There is, of 
course, general atrophy of the long bones corresponding in degree 
to the functional disability that is present. 

The onset of rheumatoid arthritis may be acute, resembling 
rheumatism, many joints being involved simultaneously. It may 
be subacute and even limited primarily to a single joint. 

The larger joints may be involved before those of the hands, 
or vice versa. In childhood the disease often begins in one of 




Rheumatoid arthritis in a child, showing the characteristic deformity, 
joint in the body is involved. 



Nearly every 



the larger joints, causing stiffness, deformity, and pain on motion. 
There is usually some local heat and infiltration, increasing and 
diminishing according to the strain or injury to which the joint 
may be subjected. In cases of this character the affection is 
usually mistaken for tuberculous disease until the involvement 
of other joints indicates the true character of the affection. As 
a rule, the affection is progressive in character, both locally and 
generally. The range of motion in the affected joint becomes 
more and more restricted, the limb becomes flexed, and, finally, 
there is practical anchylosis, usually due to adhesions and con- 
tractions within and without the joint. In those cases in which 



286 



ORTHOPEDIC SURGERY 



the cartilage is in part destroyed by the growth of granulation 
tissue from the periphery there may be actual bony union. In 




Still's form of polyarthritis, showing the general atrophy, the enlarged joints, and the 
prominence of the abdomen, due to amyloid degeneration of the liver and spleen. 

many instances the spine becomes rigid, including the occipito- 
axoid articulations, and practically every joint of the body may be 
finally involved, so that the patient is bedridden and helpless. 




The hands in the case shown in the preceding figure. 



The disease is more serious and more rapidly progressive in 
the young than in older subjects. There are periods of remis- 
sion and of exacerbation. In some instances the disease 
appears to come definitely to an end, leaving the stiffened joints. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 287 

and occasionally complete recovery takes place, but this is 
unusual. 

A peculiar form of the affection, first described by Still, 1 occurs 
in childhood. This begins usually in one or more of the larger 
joints. As a rule, it progresses rapidly, and it is accompanied 
by enlargement of the lymphatic glands, particularly those of 
the inguinal region and axilla, and of the liver and spleen. There 
is, as a rule, moderate effusion into the joints and thickening of 
the overlying tissues. As the muscular atrophy is extreme, the 
joints appear by contrast very much enlarged. The final out- 
come of the disease is anchylosis and deformity, as in the ordinary 
form. Occasionally complete recovery occurs. 

Although, as has been indicated, typical cases of rheumatoid 
arthritis differ so essentially from osteoarthritis as to be classed 
as a distinct disease, yet there are types that it is difficult to classify 
as the one or the other, and in certain instances the two forms 
may be combined in one individual. 

Etiology. — Of the etiology of rheumatoid arthritis little is known. 
Certain aspects of the disease resemble closely those caused by 
infection from without. This is particularly noticeable in those 
cases in which the disease begins in one or more of the larger 
joints. On the other hand, infectious joint disease of the ordi- 
nary form is not slowly progressive, as is rheumatoid arthritis in 
its typical form. It is probable, however, that certain forms of 
infectious arthritis of a mild character are included in what is 
now known as rheumatoid arthritis. Auto infection, due to defec- 
tive assimilation, is probably a predisposing and exciting cause, as 
it is well known that this aggravates the symptoms of the disease 
when it is once established. 

Contributing causes are apparently an inherited predisposition 
or a lack of vital resistance due, it may be, to overwork or strain, 
mental or physical, and exposure to cold or wet. 

Treatment. — In general, this must be directed to improving 
the condition of the patient by the regulation of the diet, which 
must be nourishing and easily assimilated. Exposure to cold 
and wet, and overexertion must be avoided. The use of static 
electricity, the hot-air and the electric-light baths, as general and 
local stimulants, are of service. Ichthyol ointment, the cautery, 
and the like may be employed locally. If the joints are sensitive 
motion should be restricted to the painless area by apparatus. 
Passive motion or massage that increases the pain or discomfort is 

1 Medico-Chirurg. Transactions, 1897. 



288 



ORTHOPEDIC SURGERY 



harmful, but motion should be encouraged when the disease is 
quiescent. Contraction deformity may be overcome by forcible 
manipulation, and, if necessary, by tenotomy when the disease is 
quiescent. Excision of an anchylosed joint, as of the lower jaw 
or elbow, may re-establish painless motion. 1 

The treatment of infectious arthritis is discussed elsewhere. 
It may be that a primary infection of a single joint may be the 
starting point of multiple arthritis. In such cases operation with 
the aim of removing the focus of infection may be considered. 

It may be noted as of interest that what appears to be typical 
rheumatoid arthritis in childhood may be induced apparently by 







Fig. 191 










^^m 




' ' j \ 






fin 




^^r 





Atrophic arthritis in a child affecting the joints and the spine, progressive in chai- 
acter, accompanied by enlargement of the lymphatic glands. The attitude of the head is 
characteristic of suboccipital disease. The case is apparently one of the Still type. 

infectious disease, such as diphtheria for example, and that im- 
provement, or even disappearance, of the local symptoms may 
follow intercurrent attacks of scarlatina or measles. It is possible, 
therefore, that serum-therapy may be employed in the future. 



Gout. 

Gout is comparatively of slight importance from the orthopedic 
standpoint. It affects more particularly those of middle life 

1 Whitman, Medical Record, April 18, 1903. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 289 

and it is characterized by acute inflammatory attacks followed by 
deposits of urate of sodium on or about the articular surfaces 
of the affected joints. After repeated attacks the cartilage and 
the bone may be in part destroyed, and the joint may be enlarged 
by deposits in the periarticular tissues and by the inflammatory 
thickening of the neighboring joints. The joints most often 
involved are that of the great toe, the ankle, knee, and the joints 
of the fingers. If the feet are weakened or distorted as the effect 
of gout, a proper support to distribute the weight more generally on 
the scle is often of service. The operative removal of unsightly 
deposits about joints may be considered also. The general treat- 
ment of the patient is of course of the first importance. 

Rheumatism. 

Certain forms of rheumatism, so called, are of interest from the 
orthopedic standpoint, notably those forms that affect the fibrous 
tissues and that lead to permanent changes in the joints — "plastic 
rheumatism." Undoubtedly monarticular arthritis is usually due 
to direct infection from without, as are certain forms of poly- 
arthritis. Notably those that follow infectious diseases. There are 
other forms such as are characteristic of rheumatoid arthritis, of 
gout and the like which can not be thus accounted for and in 
which defecitve assimilation and lessened resistance of the tissues 
must be considered the important factors. 

Haemophilia. 

Haemophilia is apparently a congenital weakness of the blood- 
vessels which is transmitted through females to males. In one 
family under observation since 1827, through four generations 
(207 members), there were 37 "bleeders," all males; 33 per cent, 
of the male descendants. Eighteen died from the effects of 
hemorrhage, nearly all in chidlhood. 1 In a family known to the 
writer all the males, three in number, died of hemorrhage, two 
having lived to adult age. 

Hemorrhage into a joint in this class is not uncommon, the 
knee-joint being most often involved. As a rule, it is the result 
of injury, and if the peculiarity of the patient is known the 
nature of the effusion — hemorrhagic — is hardly doubtful, particu- 

1 Deutsch. Zeit. f. Chir., Bd. lxxvi. 
19 



290 ORTHOPEDIC SURGERY 

larly as there is in many instances discoloration of the skin, either 
over the joint or elsewhere. In some instances there is no history 
of traumatism, and the swelling may be accompanied by fever. 
This is probably the effect of the hemorrhage rather than its cause. 

The peculiar interest in the affection, aside from the importance 
of a proper diagnosis, lies in the fact that the further organiza- 
tion of the effused blood may cause symptoms and changes about 
the joint that may be mistaken for those of tuberculous disease. 
There may be, for example, persistent swelling, thickening of 
the tissues, limitation of motion, and deformity combined with 
more or less weakness and discomfort. These symptoms are 
explained by the irritation of the effused blood and by its further 
absorption and organization, which necessitates the formation 
and growth of new bloodvessels; practically, a granulation tissue 
is formed that erodes the cartilage upon which the fibrinous 
deposits rest. These secondary changes resemble the early stage 
of osteoarthritis. 

Treatment. — The local treatment is rest and protection com- 
bined with stimulating applications to hasten the absorption of 
the effused blood. Several deaths have been reported from hemor- 
rhage after operative intervention in cases in which the affection 
had been mistaken for tuberculous disease. 



Hemarthrosis. 

Hemorrhage into a joint may occur in normal individuals, and 
its presence is not always indicated by superficial discoloration. 
The swelling is more resistant than is the ordinary effusion, and 
it is far more persistent. This suggests the advisability of inci- 
sion and removal of the blood clots in certain instances in order 
to relieve the joint of burden of their organization and absorption. 



Scorbutus— Scurvy. 

This affection is sometimes attended with hemorrhage into and 
about the joints. It will be considered in connection with in- 
fantile rhachitis. 

Charcot's Disease. 

Charcot's disease is a form of destructive arthritis which is 
secondary to locomotor ataxia. 



NON-TUBERCULOUS DISEASES OF THE JOINTS 291 

Pathology. — It resembles somewhat in its pathology osteo- 
arthritis. The cartilage degenerates, and, together with the 
underlying bone, is worn away by the movements of the limb. 
Accompanying the destructive process there is an exaggerated 
and irregular formation of cartilage and bone about the periphery 
of the joint. The synovial membrane is hypertrophied, and may 
be covered in places with calcareous plates; the contents of the 
joint is usually increased in quantity. 

The joint disease usually appears early in the course of loco- 
motor ataxia, often before its existence is suspected, and it is 
sometimes caused directly by injury. 




Charcot'sidisease of the knee-joint. 

Charcot's disease is said to affect about 5 per cent, of the ataxic 
patients; it is more common in the lower extremity, and one or 
more joints may be involved. In the cases tabulated by Flatow 
the distribution was as follows: 

Knee 60 ; in 13 cases both knees. 

Foot 30; " 9 " " feet. 

Hip 38; " 9 " " hips. 

Shoulder 27 ; " 6 " " shoulders. 1 

Chipault 2 notes the distribution in 217 cases, as follows: 

1 Deutsche Chir,, 1900, vol. 1. p. 28, * Le Dentu et Pelbet, Traite^'de Chir, 



292 ORTHOPEDIC SURGERY 



Knee 120 

Hip 57 

Foot .... 40 



Fifteen cases of Charcot's disease involving the spine have 
been reported. 1 

Symptoms. — The symptoms are the swelling due to the effu- 
sion, laxity of the ligaments, and deformity. There is but little 
pain, and the patient's chief complaint is of the weakness 
and distortion of the limb. In certain cases the progress of the 
affection is very rapid, and the destruction of bone may be so exten- 
sive that there is an actual luxation at the affected joint. 

Diagnosis. — If the patient is known to have locomotor ataxia 
the diagnosis will be evident, and in any event the peculiar en- 
largement, and thickening of the tissues, together with the exces- 
sive laxity of the ligaments, characteristic of this affection, which 
has been called a caricature of osteoarthritis, should call attention 
to the disease of the spinal cord. Of this the diagnostic symptoms 
are absence of tendon-jerks in the lower extremities combined 
with disorders of sensation and lessened muscular tone, and 
absence of reaction of the pupils to light. 

Treatment.— The treatment of the local disease is efficient 
support to prevent progressive distortion. Excision of the knee 
has been performed, but in many cases the bones have failed to 
unite, and on this account the operation is contraindicated. 

Disease of joints secondary to other forms of disease of the ner- 
vous system may occur. It is most common as a complication 
of syringomyelia, 19 cases of which has been investigated by Bor- 
chard, 2 in which, in contrast to locomotor ataxia, the joints of 
the upper extremity are far more often involved than of the lower. 
The symptoms of this affection are loss of sensation to pain and 
temperature, disturbance of nutrition and muscular atrophy. 
In Schlesinger's cases, the distribution was as follows : 3 



Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Other joints 8 



1 Abadie. Nouv. Icon, de la Salpfitriere, T. xiii., 1900. Cornell. Johns Hopkins Hosp. 
Bull.. October, 1902. 

2 Deutsche Zeit. f. Chir., Bd. lxxii., 1904. 
8 Die Syringomyelie, Wien, 1895, 



NON-TUBERCULOUS DISEASES OF THE JOINTS 293 

In all forms of joint disease secondary to disease of the nervous 
system the influence of injury on the ill-nourished or ill-protected 
part is recognized in the causation and in the progress of the 
disease. This indicates the principles of local treatment. 



Anchylosis. 

Anchylosis implies fixation in an attitude of deformity, and 
the term should be restricted to practical fixation caused by tissue 
changes within or without a joint, but it is often incorrectly applied 
to limitation of motion, such as may be caused, for example, by 
muscular spasm. 

Etiology and Pathology. — Anchylosis may be the result of 
actual union of two bones whose cartilages have been destroyed, 
a synostosis. This is sometimes called true, as distinguished 
from false or fibrous anchylosis. 

It may be caused by adhesions between the folds of synovial 
membrane, by adhesions and contractions of the capsular and 
other ligaments, by adhesions between the tendons and their 
sheaths, by the general adhesions and contractions caused by 
burrowing abscesses, and by the retraction and structural shorten- 
ing of muscles when the deformity has persisted for a sufficient 
time. It may be caused, also, by fractures or dislocations or by 
marginal exostoses. 

Anchylosis is usually secondary to an inflammatory affection 
of the joint during which the adhesions have formed within and 
without the capsule, and if deformity has been allowed to persist 
the muscles are atrophied and structurally shortened on the con- 
tracted side. 

Prevention and Treatment. — The danger of anchylosis may 
be lessened by the proper treatment of the disease of which it 
is a result. In tuberculous disease, for example, motion may be 
preserved in many instances by efficient protection, by which the 
area of the disease is restricted and its destructive effects checked. 
In this class of cases the joint should be fixed during the pro- 
gressive stage of the disease, in the attitude in which anchylosis, 
if it be unavoidable will least inconvenience the patient, and, if 
possible, efficient traction should be employed with the aim of 
separating the surfaces of the adjoining bones. 

Formerly it was believed that prolonged fixation of a diseased 
joint would of itself induce anchylosis, but now that it is known 
that final limitation of motion is dependent upon the severity and 



294 



ORTHOPEDIC SURGERY 



the duration of the disease, prolonged rest is believed to be the 
most efficient means of assuring motion. 

In tuberculous cases, when the disease is cured, functional use 
will ordinarily restore all the motion of which the part is capable. 
In other inflammatory affections of the joint which are usually of 
infectious origin the violence of the inital process may be restrained 
by the local application of cold or heat, or by the removal of the 




A useful form of brace for weak knee, in which the range of motion is regulated by 
means of an adjustable wheel. (Shaffer.) 



contents of the joints if the infection is severe. In all cases the 
joint should be properly supported in order to relieve pain and 
to prevent deformity. 

Passive Motion. — When the acute symptoms have subsided 
the absorption of the plastic material may be hastened by mass- 
age, the hot-air bath, and the like, and by carefully regulated 



NON-TUBEBCULOUS DISEASES OF THE JOINTS 295 

passive and active motion. Passive congestion after the method 
of Bier may be of service in certain cases. It is highly recommended 
by Blecher. 1 In the final stage, when there is no longer evidence 
of active disease, passive movements under anaesthesia may be 
of service in breaking adhesions, espe- 
cially if these are without the joint. 
Passive movements that cause per- 
sistent discomfort or pain, which are 
often employed in the treatment of 
stiff joints, even when the disease is 
active, are absolutely contraindicated. 
If, however, the limb during the 
course of the disease has become 
deformed, it should be restored to 
its proper position as soon as possible, 
even though force is required. This 
treatment is indicated in order to 
prevent secondary retraction of the 
muscles and fasciae. 

Forcible Correction. — The class of 
cases in which the limb has become 
fixed in deformity is the most favor- 
able one in which to perform the so- 
called brisement force, because the 
rectification of deformity is always 
indicated, and in accomplishing this 
there is always the prospect of regain- 
ing a certain degree of motion. If, 
however, there is no deformity the 
advisability of forced movement will 
depend on the character of the pre- 
ceding disease as well as upon the 
condition of the joint. It is rarely 
advisable to disturb a tuberculous 

joint except for the purpose of COr- Anchylosis at the hip, showing masses 
J r „ l -i of new bone. (From the Museum of the 

reCting deformity at least not Until College of Physicians and Surgeons.) 

long after the cure of the disease ; but 

if the anchylosis has followed infectious arthritis of a mild form, 
or monarticular "rheumatism," forcible manipulation may be 
attempted. If under gentle manipulation the adhesions give way 
suddenly, allowing free motion, the prognosis is good ; but if there 




1 Deutsche Zeits. f. Chir., Bd. Ix. p. 250. 



296 OR THOPEBIC SURGERY 

is a peculiar, elastic, continuous resistance, as when there are 
extensive adhesions within the joint, there is little likelihood of 
attaining motion by this means. If but slight force has been 
exerted there is usually but little reaction, and massage and passive 
motion may be employed at once; but in other instances the mani- 
pulation is followed by swelling and pain, and until these symp- 
toms have subsided fixation may be indicated. It may he men- 
tioned that anchylosis following disease is usually accompanied by 
marked atrophy of the bones, and fracture may occur during 
forcible correction. In cases of this character the rare complica- 
tion of fat embolism is sometimes encountered. 

Afterward, passive movements within the range that is practi- 
cally painless may be carried out manually, or by means of one of 
the so-called pendulum machines, by which the joint is moved 
back and forth at frequent intervals until the part is fatigued. 
Functional use, when the joint is protected by apparatus that 
limits the range of motion to the painless area, is also of service. 

The x-ray may be of value in demonstrating the condition of 
the joint and the degree of atrophy of the bones, but the history, 
which should indicate the character of the disease, and the physical 
examination are far more reliable from the standpoint of prognosis. 
In some instances operative exploration of the joint may be indi- 
cated. This permits the removal of exostoses or displaced frag- 
ments of bone after fracture that may limit motion mechanically. 
Recently the attempt has been made to prevent reunion of the 
surfaces of the adjoining bones by the insertion of thin plates 
of magnesium or other absorbable substance, as one prevents 
union in smaller joints by interposing muscular or other tissue. 
As yet the method is in the experimental stage. 

Murphy, 1 of Chicago, has reported a number of cases treated by 
interposition of flaps of fibrofatty tissue. At the knee, for example, 
the joint is exposed by raising a broad anterior flap of skin. The 
capsule is then removed, only the lateral ligaments being preserved. 
The bones are then separated completely, obstructions to move- 
ment cut away, and broad flaps of fibroin uscular tissue from 
the lateral aspect of the muscles on one or both sides of the joint 
are turned down and are inserted between the bones and beneath 
the patella if this is adherent. The skin is then united. Later 
massage and passive motion are employed. 

This operation may be of service in certain carefully selected cases 
particularly those in which the destruction of tissue has been 

1 Journal of the American Medical Association, May, 1905. 



NON-TUBERCULOUS DISEASES OF THE J0IN1S 297 

slight and in which the patella is free. As a rule, however, at 
least in the working class, an anchylosed joint of the lower ex- 
tremity is far more serviceable than one in which a few degrees 
of motion persist. For whenever the joint is strained by an 
unguarded movement the patient suffers discomfort, and motion 
uncontrolled by the muscles, as in the cases in which the patella 
is fixed, is worse than useless. 

At the ankle-joint removal of the astragalus will often restore 
motion, and in the upper extremity excision of the joint at the 
shoulder or elbow is equally efficacious. 



CHAPTER VII. 

TUBERCULOUS DISEASE OF THE HIP-JOINT 

Synonyms. — Hip disease, morbus coxse. 

Hip disease is a chronic destructive disease that results in loss 
of function and deformity. At one time a number of pathological 
processes and even simple deformity (coxa vara) were included 
under the title, but it is now limited to tuberculous disease. 




Section of the hip-joint at the age of eight years, showing the epiphyses and the relation 
of the capsule. (Schuchardt.) At birth the entire upper extremity of the femur is carti- 
laginous. According to Jacinsky, ossification begins in the head of the femur at about the 
tenth month; in the trochanter major at from the fourth to the eighth year; in the tro- 
chanter minor at the eleventh year. Ossification is complete at all points at about the 
eighteenth year. Range of motion at the hip-joint. Extension to 20 degrees beyond the 
horizontal; flexion to 70 degrees; total 140 degrees. Abduction, adduction, and rotation 
are most free when the limb is flexed 60 degrees At this point the range of adduction is 
55 degrees, of adduction 35 degrees; total 90 degrees. Outward rotation 40 degrees, in- 
ward rotation 20 degrees; total 60 degrees. If the limb is completely extended the range 
of abduction is about 40 degrees; adduction, 15 degrees. 1 

Pathology. — Tuberculous disease of the hip-joint usually 
begins in several minute foci in the neighborhood of the epi- 
physeal cartilage of the head of the femur. Here the circulation 
is most active, and here the newly-formed bone is least resistant. 
Thus the bacilli, carried by the blood, are more often deposited 

1 R. du Bois-Raymond, Berlin, 1903. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



299 



at this point, where, under favoring conditions, the disease is 
established. These foci coalesce and an area of infected granu- 
lations replaces the normal structure. If the local resistance is 
sufficient the disease may be confined to the interior of the bone, 
but in most instances it gradually forces its way into the joint 
and the granulation tissue, spreading under and over the carti- 
lage, destroys it in its progress. The lining membrane of the 
joint becomes involved in the 

disease, and, finally, the ad- FlG - 19& 

joining surface of the acetabu- 
lum as well. In a certain 
indeterminate number of cases 
the tuberculous process begins 
about the epiphyseal junc- 
tions of the acetabulum, and 
primary disease of the synovial 
membrane may occur, although 
this is certainly uncommon in 
childhood. 

From the clinical stand- 
point, primary disease of the 
acetabulum may be inferred 
when the patient is particu- 
larly susceptible to movements 
of the trunk, or when lateral 
pressure on the pelvis causes 
pain; or when a Roentgen 
picture shows greater erosion 
of the acetabulum than of the 
head of the femur (Fig. 209). 
There are other cases in which 
the symptoms of the disease 
are slight and in which swell- 
ing about the joint is noticeable; in such cases it is probable 
that disease of the synovial membrane is present without marked 
involvement of the head of the femur or of the acetabulum. 

In the common or osteal form of disease, while the tuber- 
culous process is still confined within the head of the femur, 
the joint shows evidences of sympathetic irritation; the synovial 
membrane is congested, and the fluid within the joint is increased 
in quantity. These changes become more marked as the disease 
progresses, the lining membrane becomes thickened and granular, 




" Wandering of the acetabulum" in hip disease. 
(Krause.) 



300 



ORTHOPEDIC SURGERY 



and adhesions between its folds lessen the capacity of the joint. An 
amount of tuberculous fluid, large enough to be recognized as an 
"abscess," is present in about half the cases at some time during 
the course of the disease. This fluid usually finds an exit from 
the capsule into the tissues of the thigh, but occasionally it may 
pass through the acetabulum into the pelvis. In rare instances 
the disease may not enter the joint, but may find an opening 
in the neck outside the capsule. In such cases the joint is, in 
most instances, finally involved unless the disease is removed 




Erosion of the head of the femur and of the upper border of the acetabulum. Formation 
of new bone (osteophytes) about the acetabulum. 

by surgical means. There are cases, also, in which the disease, 
confined within the head of the bone, so weakens it that it 
becomes distorted to a marked degree without destruction of the 
cartilage. 

If the disease involves the neck of the bone it may sink down- 
ward, a form of coxa vara; or the head of the bone may be 
separated at the epiphyseal junction, with consequent upward 
displacement of the shaft. 

In by far the larger number of cases the joint is perforated 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



301 



and the head of the femur and the acetabulum are eroded to a 
greater or less degree. In such instances the destructive effects 
of the disease are increased by the pressure and friction of the 
softened bones on one another, aggravated by the spasm of the 
surrounding muscles. Thus at the upper margin of the acetabu- 
lum and the inner and upper surface of the femur there is greater 
loss of substance than elsewhere (Fig. 197). 

The appearances in advanced cases of this type, as seen at 
operation or autopsy, may be summarized somewhat as follows: 
The head of the femur is deeply eroded, its cartilaginous cover- 




Erosion of the head of the femur and of the upper margin of the acetabulum. 
A, anterior superior spine. B, anterior inferior spine. 



ing has practically disappeared, or is in part still adherent in 
necrotic shreds. It lies in seropurulent fluid, embedded in the 
gelatinous necrotic granulations that line the capsule and partly 
fill the acetabulum. 

In certain instances the disease may extend to the adjoining 
surface of the pelvis, or the acetabulum may be perforated (Fig. 
199), or the medullary cavity of the femur may be implicated. 
Occasionally the disease may be from the first of an acute de- 
structive type, whose course is but little influenced by treatment, 



302 



OR THOPEDIC SURGERY 



but in the majority of cases the progress of the disease and its 
destructive effects may be greatly modified by efficient protection 
of the joint. 

In the natural cure of the disease the focus within the bone, if 
it be small, may be absorbed and replaced by scar-like tissue; or 
the products of the disease may be separated from the healthy 
parts, and discharged by abscess formation. In other instances 
a part in which the disease is still active may be enclosed within 
the newly-formed tissue. Here the process may remain quiescent 
or it may cause relapse, many years after the apparent cure. 
Or portions of necrosed bone, enclosed within the capsule, may 
prolong suppuration after the tuberculous disease has ceased to 
progress. 

Etiology. — The etiology of tuberculous disease is discussed in 
Chapter V. 

Relative Frequency. — Tuberculous disease of the hip-joint is the 
most common and the most important of the affections of the 
joints, ranking second to Pott's disease. In a total of 7845 cases 
of tuberculous disease treated in the out-patient department 
of the Hospital for Ruptured and Crippled during a period of 
fifteen years 3203 were Pott's disease, 2230 were hip disease, 
while the remaining 2412 cases included all the other joints. 

Age. — Hip disease is essentially a disease of early childhood, 
although no age is exempt. In a series of 1000 consecutive cases 
of hip disease tabulated for me by Ashley, formerly an assistant 
in the department, 88.1 per cent, of the patients were in the first 
decade of life, and 45.6 per cent, of these were from three to five 
years of age, inclusive. 







AGE AT ] 


NCIPIENCY. 




Less than lyear 


. 9 


Between 16 and 17 years . 


11 


Between 1 and 2 years 


. 39 


17 " 18 " 


4 


2 


3 


. 107 


18 " 19 " 


5 


3 


' 4 " 


. 155 


19 " 20 " 





4 


' 5 " 


. 158 


20 " 21 " 


3 


5 


' 6 " 


. 139 


21 " 22 " 


3 


6 


. 7 .. 


. 90 


22 " 23 " 


1 


7 


' 8 " 


. 51 


23 " 24 " 


2 


8 


' 9 " 


. 51 


24 " 25 " 


3 


9 


' 10 " 


. 40 


25 " 26 " 


1 


10 


' 11 " 


. 33 


26 " 27 " 


1 


11 


'12 " 


. 19 


27 " 28 " 


1 


12 


' 13 " 


. 18 


28 " 29 " 


1 


13 


'14 " 


. 23 


30 " 33 " 


4 


14 


' 15 " 


7 


33 " 36 " 


1 


15 


' 16 " 


. 8 


Age not stated 


12 



* Sex. — SexTexercisesIbut little] % influence in t [predisposition, 
although the disease is slightly more common_among males than 



TUBERCULOUS DTSEASE OF THE HIP-JOINT 



303 



among females. In the 1000 cases referred to, 553 (55.3 per 
cent.) were in males, 447 were in females. 

In 3307 cases treated at the same institution, 53 per cent, were in 
males. 

Side Affected. — In disease of this as of other joints the right is 
somewhat more often affected than the left. In the 1000 cases 
506 were on the right side, 483 were on the left, and in 11 cases 
both joints were involved. In a larger number of cases treated 
in the department 53 per cent, were of the right joint. 

Symptoms. — Tuberculous disease of the hip-joint is a chronic, 
insidious affection characterized by occasional exacerbations of 
more acute symptoms that 

may be induced by over- FlG - 199 

strain or injury, by a more 
rapid advance of the de- 
structive process, or by 
infection with pyogenic 
germs. In the early stage 
of the disease the joint is 
simply sensitive, and the 
symptoms vary with the 
activity of the disease, 
which may increase the 
tension within the bone, 
the susceptibility of the 
patient, and the strain to 
which the weakened part 
is subjected. This sensi- 
tiveness is first indicated 
by the involuntary adapta- 
tion of the body to the 

weakness of the affected joint, or, as popularly expressed, the 
patient favors the leg. 

The important symptoms of disease of the hip-joint, in the 
sense of attracting attention to the affection, are pain and limp. 
Of the two, pain is much the less significant. Hip disease is by 
no means a painful disease, and although patients are often 
brought for treatment because of pain, it is usually apparent, 
on examination, that the disease must have existed long before the 
acute exacerbation called attention to its serious character. Even 
in cases in which the disease is far advanced, one may be assured 
that the patient has never complained of pain. 




Erosion of the head of the'f emur and destruction 
of the acetabulum. 



30 4 R TH OPE DIC SURGERY 

Pain. — The characteristic pain of hip disease is "pain in the 
knee," referred, as is the pain of Pott's disease, to the more im- 
portant distribution of the nerves, whose filaments are irritated 
by the local process. The hip-joint is supplied by the anterior 
crural, the sciatic, and the obturator nerves, but the pain is more 
often referred to the distribution of the last, thus to the inner 
side of the knee. Pain so persistently referred to the knee is 
misleading, and patients are often treated for obscure affections of 
this joint long after an examination of the hip would have made 
the diagnosis evident. 

The pain of hip disease is induced by sudden or unguarded 
movements, or by injury; therefore, in many instances, it is rather 
an occasional than a constant symptom. Persistent pain almost 
always indicates the increased tension either within the bone or 
within the joint that accompanies abscess formation. 

Night Cry. — Pain at night is of importance, as it more 
often attracts attention than the occasional complaint of discom- 
fort during the day. It is a common symptom when the disease 
is at all acute in character, and it is often present when pain, 
during the period of activity, is apparently absent. It may be 
inferred, as an explanation of this symptom, that the joint 
gradually becomes more sensitive under the strain of use during 
the day, and that the relaxation of the voluntary and involuntary 
protection of the muscles allows sudden movements that excite 
spasmodic muscular contractions, which force the sensitive parts 
against one another. This causes a sharp cry. If the disease 
is acute, the child is usually awakened and is found holding the 
thigh with the hands or pressing upon the limb with the other 
foot, the evidence of pain being unmistakable. In the less sen- 
sitive conditions the patient does not wake after crying out, but 
simply moans or is restless for a time. If awakened it makes no 
complaint of pain and the cry is supposed to be caused by a "bad 
dream." This cry may be repeated several times, more often in 
the early part of the night. 

Direct local pain and sensitiveness to pressure are unusual 
unless the disease is acute in character, or unless the tissues over- 
lying the joint are implicated, as in abscess formation. 

Limp. — The limp is the most important of what may be classed 
as the preliminary signs of the disease. A limp is a change in 
the rhythm of the gait, a long step alternating with a shorter 
step. It is evident that any interference with the function of 
the limb will cause this irregularity which can be concealed or 



TUBERCULOUS DISEASE OF THE HIP-JOINT 305 

diminished only by accommodating the normal member to its 
disabled fellow. Thus an inequality in length or a limitation of 
motion in the joint or distortion, or weakness or pain, may cause 
an arrhythmical gait. Several of these factors may be combined 
in the causation of the final disability of hip disease, but in the 
beginning, the limp is due rather to sensitiveness than to any 
marked restriction of function. Thus the patient favors the 
joint by resting on the limb for a shorter time than on its fellow, 
and by bearing more weight upon the front of the foot than upon 
the heel. If the joint is very sensitive, the patient may bear 
practically all the weight upon the front of the foot, slight plantar 
flexion at the ankle being combined with slight flexion at the 
knee and hip; thus the jar of direct impact of the heel upon an 
extended leg is avoided. 

The limp is practically a constant symptom of hip disease; 
it is as a rule more noticeable in the morning or on changing from 
an attitude of rest than during activity. The limp may be inter- 
mittent even, although it is probable that in most instances some 
change from the normal gait might be detscted by a practised eye. 

The other symptoms of disease of the hip-joint are more prop- 
erly physical signs that become evident on examination. These 
are: stiffness, distortion, change of contour, and atrophy. 

Stiffness, due to reflex muscular spasm, is by far the most 
important sign of the disease. It is the instinctive expression of 
the inability of the joint to perform its full function and espe- 
cially to allow the full range of motion which increases the strain 
upon the joint. It is the first and the last sign of disease; it prob- 
ably precedes the limp, and it remains long after pain has ceased 
to be a symptom, and until repair is complete. 

Reflex muscular spasm limits motion in every direction to a 
greater or less degree. At an early stage of the disease the motion, 
whether voluntary or passive, may be perfectly free throughout 
three-fourths of its normal range, but when the limit allowed 
by the muscular protection is reached motion is checked by a 
peculiar elastic resistance. If an attempt is made to force the 
limb beyond the limit set by the muscular resistance the entire 
body follows the movement. The contraction of the surrounding 
muscles, including those of the trunk even, may be appreciated 
by the eye and by the hand, and the expression of the patient's 
face shows discomfort and apprehension. 

The degree of muscular spasm corresponds to the sensitiveness 
of the joint rather than to the area of the destructive disease. 

20 



306 ORTHOPEDIC SURGERY 

Thus it may vary from day to day and even from hour to hour, 
and in the acute exacerbations of the disease motion may be for a 
time so absolutely restricted as to simulate anchylosis. 

Reflex muscular spasm is an infallible sign of a sensitive joint; 
it is, of course, not diagnostic of the tuberculous process, but 



Apparent lengthening. Fixed abduction of 45°. When the anterior superior spines are 
on the same plane, as in the illustration, the deformity is evident. (See Fig. 201.) 

unless it is the direct effect of injury it indicates disease, and 
if this disease is chronic and confined to a single joint it is, in 
childhood at least, almost always tuberculous in character. In 
the early stage of hip disease the restriction of motion is caused 
almost entirely by reflex muscular spasm, as is shown by the fact 
that when the patient is anaesthetized the range of motion becomes 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



307 



practically free. As the destructive process progresses motion 
is still further restrained by adhesions and contractions within 
and without the joint. 

Distortion of the Limb. — Persistent reflex muscular spasm is 
always accompanied by a certain change in the attitude of the 





Apparent lengthening. When the ab- 
ducted limb is brought to the median line 
the pelvis is so tilted that it seems longer. 
(See Fig. 200.) 



Right-angle flexion in hip disease partly 
concealed by the compensatory lordosis and 
by the flexion at the knee and ankle. 



limb, slight flexion being the earliest indication of distortion here 
as at every other joint. With flexion there is usually abduction 
with slight outward rotation of the limb. 

Flexion, Abduction, and Outward Rotation. Appar- 
ent Lengthening. — This is the passive attitude or the attitude 



308 



ORTHOPEDIC SURGERY 



of rest in the normal condition, and in disease it shows the in- 
stinctive adaptation of the limb to a sensitive joint which is still 
capable of a certain amount of work. The flexion lessens the 
direct jar and the abduction throws the limb aside, as it were, 
from the active attitude, making it a prop and adjunct of its 
fellow instead of an active aid in the propulsion of the body. 
This attitude is not voluntarily assumed by the patient; it is 
involuntary and persistent. The limb is apparently lengthened, 
because it is held away from the axis of the body, and in order 
to bring it into the middle line and parallel to its fellow the pelvis 
must be tilted downward on the diseased side and upward on 
the other. The sound limb is drawn upward and the affected 
limb is lowered according to the degree of abduction (Fig. 201). 




The degree of fixed flexion 



shown when the lumbar spine : 
by flexing the other t high. 



held in contact with the table 



If, however, the anterior superior spines of the pelvis are placed 
upon the same plane, the distortion becomes evident (Fig. 200). 
Thus the deformity of the limb is concealed or compensated by a 
tilting of the pelvis which twists the lumbar spine into a lateral 
convexity toward the lower side. 

In the same manner persistent flexion of the limb is concealed 
by a tilting of the pelvis forward, and by an increased hollow- 
ness or lordosis of the lumbar region (Fig. 202). Normally, in 
childhood at least, the lumbar spine and the popliteal surface of 
the knee should touch the table when the patient lies upon the 
back; but if the thigh is fixed in flexion the lumbar region must 
be arched and raised from the table when the leg rests upon it. 
Thus, in order to make the flexion apparent, the lumbar spine 
must be forced to touch the table, and this is possible only when 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



309 



the limb is raised to a degree corresponding to the deformity 
(Fig. 203). If the spine were rigid, as in spondylitis deformans, 
this compensation would be impossible, and if the patient were 



Fig. 205 




Apparent shortening. The adduction of 
the right thigh is made evident by the invol- 
untary crossing of the legs when the anterior 
superior spines are on the same plane. 



Apparent shortening. When the adducted 
limb is placed in the line of the body, the 
pelvis is tilted upward on the adducted side 
and downward on the other. The patient has 
compensated for the apparent shortening by 
flexing the knee on the sound side. This 
does not appear in the photograph. 



placed upon his back the leg could not be brought down to the 
table; or if both limbs were distorted, as is sometimes the case 
when both hip-joints are diseased, the limbs would remain widely 
separated or crossed over one another, according to the character 
of the deformity. 



310 OB THOPEDIC S UE GER Y 

Flexion, Adduction, and Inward Rotation. Apparent 
Shortening. — If the disease is of a more acute type, and if loco- 
motion be permitted, the attitude usually changes to one of 
increased flexion; and adduction and inward rotation replace 
abduction and outward rotation. This attitude is an indication 
that the joint is so disabled as to be of little service, thus the limb 
is instinctively drawn into a more protected attitude, where it 
may be used as little as possible. If the patient is confined to 
the bed, or does not walk, as in hip disease in infancy, the atti- 
tude of abdustion may persist, although the muscular spasm may 
be intense. Thus it would appear that locomotion has a distinct 
influence on the character of the distortion. 

Adduction causes apparent or practical shortening; for in 
order to bring the adducted limb to the middle line of the body 
and parallel to its fellow, the pelvis must be tilted upward on 
the affected side and downward on the other, the lumbar spine 
bending with the convexity toward the lower side (Figs. 205 and 
208). If the level of the pelvis be restored, the adducted limb 
will be crossed over its fellow, and the deformity is made evident 
(Fig. 204). 

As has been stated, the attitude of flexion, adduction, and 
inward rotation, if it appears early in the disease, is usually an 
indication of acute and disabling pain and of corresponding in- 
tensity of muscular spasm. But in most instances it is associated 
with the later and destructive stage of the disease, and it by no 
means indicates that the preceding symptoms have been more 
than ordinarily acute. In fact, it is the attitude characteristic 
of a so-called "natural cure" (Fig. 206) when mechanical treat- 
ment has not been employed. It more often accompanies the 
later course of the disease, because its causes are in great degree 
mechanical. 

This is illustrated by Koenig's statistics of 499 cases of hip 
disease. 

In 267 cases the limb was abducted, and in 31 per cent, of 
these there was actual shortening. 

In 232 cases adduction was present, and in 70 per cent, the 
limb was shorter than its fellow. 1 

The mechanics of the distortion as indicative of the destructive 
stage of the disease will be made clearer if it be compared to the 
deformity caused by dorsal dislocation of the hip. In this dis- 
placement the femur, forced upward and backward upon the pelvis, 

1 Koenig, Das Hoeftgelenk, Berlin, 1902. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



311 



is fixed in an attitude of extreme flexion, adduction, and inward 
rotation. Each of the destructive changes of hip disease, the 
enlargement of the acetabulum, the depression of the neck of the 
femur, and the erosion of the head of the bone, is accompanied 





The final effect of hip disease when un- 
treated. The natural cure, with flexion and 
adduction. Compensatory recurvation of 
the knee on the sound side is also shown. 



Untreated hip disease. Flexion deform- 
ity to nearly a right angle with the body. 
Trochanter two inches above Nelaton's line. 
Compensatory lordosis. 



by an elevation of the femur upon the pelvis or an approximation 
to a dorsal displacement (Fig. 207). If this displacement occurs 
suddenly, as in certain cases of acute disease attended by effu- 
sion and rupture of the capsule, the limb immediately assumes an 



312 



ORTHOPEDIC SURGERY 



attitude typical of dorsal dislocation; but in the ordinary form 
of disease the changes are very gradual; the pelvis and the femur, 
being in most instances undeveloped, more readily accommodate 

themselves to the changed con- 
ditions, so that the actual dis- 
tortion is less marked than in a 
similar subluxation of traumatic 
origin in the adult, but the simile 
will serve to illustrate the mechan- 
ical causes of distortion, and why 
such deformity may recur after 
correction, even though the disease 
has entirely disappeared. Out- 
ward rotation of the limb is usu- 
ally associated. with abduction, and 
inward rotation with adduction, 
but in certain instances outward 
rotation may be combined with ad- 
duction and inward rotation with 
abduction. These irregular atti- 
tudes are more often observed in 
cases that have received mechan- 
ical or operative treatment than in 
those in which the disease has 
pursued its natural course. 

As has been stated, the distor- 
tions of the early stage of hip dis- 
ease are caused almost entirely 
by muscular contraction which re- 
laxes under the influence of an 
anaesthetic, but after a time the 
attitude is confirmed by accom- 
modative changes in the muscles 
and fasciae, and by contractions 
and adhesions about the capsule. 
Thus an attitude that was origi- 
nally a symptom may persist after 
the cure of the disease. 
One may conclude then that flexion is practically an invari- 
able symptom in hip disease because complete extension, the 
attitude that puts most strain upon the joint, is first restricted. 
Flexion in the milder or in the earlier class of cases is usually 




Stage of apparent shortening. The left 
limb is adducted 35°, making an apparent 
shortening measured from the umbilicus 
of more than two inches. In order to 
reduce the obliquity of the pelvis, the 
adducted leg must be crossed over its 
fellow. (See Fig. 204.) The apparent 
shortening is compensated by the flexion 
at the knee on the sound side. This is 
not made clear in the photograph. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 313 

combined with abduction and outward rotation, the attitude of 
inactivity. Increased flexion, accompanied by adduction and 
inward rotation in the early stage, is an indication of a more 
acute phase of the disease. If the attitude is retained for a time 
it becomes fixed by accommodative changes in the tissues; thus 
the distortion is not unusual in cases in which the damage to the 
joint may be very slight, as, for example, when it follows rheu- 
matism or some form of infectious arthritis. But in most instances 
the attitude is indicative of more advanced disease and of destruc- 
tive changes within the joint. 

Changes in the Contour of the Hip. — In the early stage of the 
disease the changes in contour are caused in great part by the 
attitude of the limb. If, as is usual, it is flexed, abducted, and 
rotated outward the buttock appears somewhat flatter and broader 
than its fellow. The gluteofemoral fold is lower because of the 
tilting downward of the pelvis and it is shallower because of the 
flexion. If the thigh is adducted, the gluteal fold will be ele- 
vated and shortened. On the anterior aspect, the inguino- 
femoral fold is deepened and lengthened by flexion and adduction 
while abduction makes it less noticeable. Hoffman has called 
attention to the fact that the genitals and the intergluteal fold 
point toward the adducted and away from the abducted thigh. 
Adduction makes the trochanter more prominent, and abduction 
makes it less prominent. 

To these primary changes in the appearances must be added 
the effect of atrophy or of infiltration and swelling, due directly 
to the disease. A certain amount of swelling indicating effusion 
into the joint is often apparent in the inguinofemoral region, and 
infiltration of the deeper tissues is sometimes evident on palpation. 
In such cases there is usually a certain sensitiveness to deep pressure 
behind or in front of the trochanter. Palpable or evident abscess 
is unusual in the early stage of the disease. 

Atrophy. — Atrophy is an important sign of joint disease. It is 
often appreciable to the eye and to the hand, and it is always 
demonstrable by measurement. It is an important symptom, 
because, if well-marked, it shows that the aisease must have 
existed for some time, whatever may be the statement of the 
patient's relatives. 

The atrophy affects the muscles of the entire limb, although it 
is somewhat more marked in the muscles of the thigh than in 
the calf. In the ordinary case of hip disease in childhood, when 
the patient is first brought for treatment, it averages from one- 



314 ORTHOPEDIC SURGERY 

half to one inch in the thigh and somewhat less in the calf. As 
has been stated elsewhere, atrophy of muscles is usually accom- 
panied by a corresponding atrophy of bone as well. 

The Causes of Atrophy. — Admitting that the secondary 
causes of atrophy are somewhat obscure, one cause, and by far 
the most important, is very evident. This is physiological disuse, 
and thus diminished nutrition of the limb, which has become 
incompetent to carry out its full function. Atrophy is a constant 
symptom of simple disuse in the absence of disease. If a bone 
has been broken, atrophy of the surrounding muscles is observed. 
If anchylosis of a joint occurs from any cause, whether it be from 
injury or disease, atrophy of the muscles, whose function has been 
abolished, follows. Even the atrophy caused by disease of the 
hip-joint is greater when the limb has been fixed in apparatus than 
when none has been applied, although the treatment has allayed 
the pain and has checked the progress of the disease. This 
point is illustrated by the observations of Brackett, 1 who contrasted 
the atrophy of hip disease in two groups of patients, in one of 
which motion had been permitted, while in the other fixation, as 
complete as possible, had been employed. In the first group the 
average of atrophy was but 1 per cent, of the volume of the thigh 
and 0.89 per cent, of that of the leg, as contrasted with 23 per 
cent, and 17 per cent, in the second class. 

According to the investigations of Bum, 2 simple fixation of a 
sound limb induces more rapid atrophy than is caused by dis- 
ease of a joint when function has been permitted. 

The atrophy caused by physiological disuse and diminished 
nutrition affects all the components of the limb. The skin be- 
comes thinner, the muscles lose in volume, the contractile sub- 
stance is replaced in part by fat and by fibrous tissue, and the 
medullary canals of the bones enlarge at the expense of the cor- 
tical substance. 

In childhood, the period of rapid development, disuse often 
causes a retardation in growth of the entire extremity. This 
may be apparent in the foot when it is placed by the side of its 
fellow, while the diminished growth in the length of the limb 
may be demonstrated by measurement. Brackett, in a series of 
cases, found this shortening to be distributed as follows: average 
loss of the femur 6.6 per cent, and of the tibia 5.4 per cent, of 
the normal length. 

1 Transactions American Orthopedic Association, vol. iv. 
5 Zeit. f. chir., December 9. 1905. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



315 



This atrophy, the direct result of the disease and of the long- 
continued disuse during the period of repair, becomes less notice- 
able after function is resumed, the degree of final inequality 
depending upon the severity of the disease, the duration of the 
treatment, and upon the impairment of function. But even 
when free motion in the joint is retained, a certain amount of 
atrophy always persists and the loss in growth is never replaced. 




Early stage of disease of the left hip-joint (to the right in the picture) of the synovial 
type, showing irregularity in the shape of the acetabulum. 

If motion is completely abolished the muscles about the joint lose 
in bulk in proportion to the disuse of their normal function; whereas 
the bones of the limb which are still used to support the weight 
retain to a greater degree their normal size and length. Contrasted 
with this atrophy there is a relative hypertrophy of the sound 
limb, which is forced to assume more than its share of work. 



316 



ORTHOPEDIC SURGERY 



Actual Shortening. — Actual shortening of the limb is a 
common effect of hip disease, but it can hardly be called a symp- 
tom, for it is not present at the onset of the disease. 

The causes of actual shortening may be classified as: 

1. Disuse of the limb. I 

2. The effect of the disease upon the epiphysis of the head of 
the femur. ■ 




Advanced disease, showing wandering of the acetabulum and the obliquity of the pelvis 
due to adduction. Actual shortening one inch, apparent shortening three inches. 



3. The more general destructive effects of the disease that 
cause upward displacement of the femur. 

(a) Erosion of the head. 

(b) Erosion of the acetabulum. 

(c) Depression of the neck of the femur. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 317 

Disuse, throughout a long period of treatment, causes a certain 
amount of shortening of the entire limb. To this the shorten- 
ing of the bones of the leg and of the foot may be attributed in 
great part. If the epiphysis of the head of the femur is destroyed 
in whole or in part or if the disease hastens its union with the 
neck a certain loss of growth must follow. This is, of course, 
slight in degree, because this epiphysis is relatively unimportant 
compared with that at the lower extremity of the femur. From 
these two causes, the atrophy of disuse and the effect of the dis- 
ease upon the epiphysis, relative shortening of the limb may in- 
crease after the disease is cured. 

Erosion of the head of the femur and of the upper border of 
the acetabulum are usually combined in those cases in which the 
shortening is in part dependent on upward displacement of the 
trochanter (Fig. 197). Depression of the neck of the femur to 
an appreciable degree is less common. Elevation of the trochan- 
ter, due to one or more of these causes, a form of subluxation, 
is very common, particularly so in those cases in which the pro- 
tective treatment has been inefficient. Greater displacement 
follows fracture of the weakened neck and complete absorption 
of the head, and occasionally a fairly normal femur may be act- 
ually dislocated as a result of sudden effusion into the joint with 
rupture of the capsule — a form of pathological dislocation. 

It may be stated also that in partial or complete displacement 
forward (anterior subluxation) is not uncommon. In such cases 
there is marked outward rotation of the limb with but slight 
shortening, the head of the bone presenting by the side of the 
anterior inferior spine of the pelvis. 

Retardation of Growth. — As has been stated, all the com- 
ponents of the limb are affected by the retardation of the growth. 
Brackett's observations on this point have been mentioned, and 
the table on the following page, showing the relative measures 
of the bones in cases under treatment by Dollinger, 1 of Budapest, 
presents the subject in a convenient form: 

1 Zeits. f. Orth. Chir., 1892, Bd. i. 



318 



OR THOPEDIC SURGER Y 





Age at 


Duration of 


Length of 




Length of 






inception. 


disease. 


femur in cm. 




tibia in cm. 




No. of 








Differ- 
ence. 




Differ- 


case. 


















ence. 












Dis- 






Dis- 








Years. 


Months. 


Years. 


Months. 


eased. 


Normal. 




eased. 


Normal. 




1 


8 


6 


... 


6 


28% 


28 


+y a 


24 


24 




2 


3 


4 




8 


23 


24 


1 


19 


19 




3 


2 


10 


"i 


8 


24 


24 




19 5 


19.5 




4 


5 




2 




29 


30 


"i 


23.5 


23.5 




5 


6 




2 




27 


28 


l 


23 


23 




6 


7 




2 




32 


33 


l 


27 


27 




7 


9 




2 




37 


37 




30 


30 




8 


1 




4 




22 


24 


"2 


18.5 


19 


0.5 


9 


13 




4 




38 


41 


3 


34 


34 




10 


4 


"6 


5 




32 


34 


2 


27 


27 




11 




2% 


6 




26 


27 


1 


21^ 


23 


i" 


12 


13 




7 




38 


40 


2 


33 


33 




13 


2 




8 




35 


36 


1 


28 


28 




14 


6 




8 




38 


38 




31 


32 




15 


11 




8 




40 


44 


"4 


34 


34 




16 


5 




10 




45 


46 


1 








17 


5 




11 




41 


44 


3 


si 


37 


6" 


IS 


6 




14 




44 


48 


4 


36 


39.5 


3.5 


19 


2 




18 




36 


46 


10 


38 


38 




20 


2 




28 




44% 


45 


K 


37.5 


37.5 





A similar investigation of thirty-three cases under treatment 
at the Hospital for Ruptured and Crippled, New York, has been 
made recently by Taylor. In these cases the shortening of the 
bones was found to be more generally distributed than in those 
reported by Dollinger, as is illustrated by the accompanying table. 

Dr. Taylor measured also ten cases of unilateral poliomyelitis, 
in patients of an average age of thirteen years, with an average 
duration of disability of ten years. The average shortening in 
these cases was one and three-fourths inches, and in no case was 
it greater than two and one-half inches. It will be noted that 
the retardation of growth in this group corresponds closely with 
that of the third group of cases of hip disease, in which the disa- 
bility was of about the same duration. Taylor concludes that 
the retardation of growth from unilateral hip disease in childhood 
is dependent in great degree upon the duration of the disability 
and upon the corresponding restraint of function. Similar obser- 
vations on fifty cases of hip disease have been recorded by Hibbs. 1 

Actual Lengthening of the limb as the result of disease is 
occasionally observed during the active stage of the disease, 
caused, it may be inferred, by granulations within the acetabulum 
that press the femur outward and downward. Actual lengthen- 
ing of the femur is uncommon, but it does occur, induced, it may 
be, by stimulation of the growth of the epiphysis of the head; 
but the most extreme instances are those in which the upper por- 
tion of the shaft of the femur is involved, the lengthening being 



New York Medical Journal, December 16, 1899. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



319 



the effect of an irritative hypertrophy. This is more commonly 
the result of extra-articular disease. 













Dura- 






Shortening in inches. 






Sex. 


Age. 


Side. 


Dura- 
tion of 


tion of 
treat- 


Abscess. 












Case. 




















disease, 


ment, 




Entire 


















years. 


years. 




limb. 


Femur. 


Tibia. 


Foot. 


Patella 


1 


F. 


3% Left 


1 


1 


No 


A 


_ 


1 


% 


1 


2 


M. 


7 < Right 
5 Left 


VA 


1 


No 


Ya, 


X 


% 


3 


M. 


2 


1 


No 


Vb 


K 


% 


4 


M. 


5 Right 


2 


VA 


No 


Va 


K 


Yt 


% 


K 


5 


M. 


6A '■ Left 


2K 


1^ 


Yes 


% 


Ya 


3/8 


3/8 


K 


6 


P. 


4% iLeft 




3 


No 






— 




Ya 


7 


F. 


b*4 Right 


3 


— 


No 


13 ^ 


— 


K 


— 




8 


M. 


6 Right 


3 


2% 


No 


K 


M 


A 


% 


9 


V 


13 Left 


&A 


2 


No 




% 


% 


V* 


10 


F. 


7 Leit 


■»72 

3% 
3% 


3K 

3% 


No 


1% 


% 


% 


A 


Ya 


11 


M. 


7 Right 


Yes 


1 


Ya 


% 


6 A 


3/8 


12 


F. 


11 Right 


IK 


No 


iH 


Ya 


% 


* 


A 


13 


F. 


9 


Left 


&A 


No 


iK 

1 




a 


Vs 



Average 



I... 



2% 



a m 



14 


M. 


^ 


Right 


4 


4 


No 


1 


K 


K 


I 


K 


15 


F. 


8K 


Right 


4 


4 


No 


1 


ii 


% 


*i 


16 


F. 


12 


Right 


5 


4 


Yea 


3 1 / 


K 


1« 


■* 


X 


17 


K. 


11 


Right 


5% 


4 


Yes 


2* 


l 


J 4 


% 


IS 


K. 


13 


Left 


6 


:s 


No 




A 


3% 


H 


K 


19 


F. 


12 


Left 


6 


4 


No 


% 


Ya 


3 / 


% 


20 


1'. 


10 


Left 


6% 


4 


No 


IK 


Ya 


V 




§ 


21 


M. 


14 


Left 


7 


X 


Yes 


2% 


X 


3 / 


34 


22 


K. 


15 


Right 


7 


5 


No 


2'4 


X 


1 


a 


X 


23 


M. 


9K 


Right 


' 


A 


Yes 


IK 


— 


« 


X 


Average 


11 1 ... 


5% 


3% 




1% 


K 


Va 


K 


3/8 



24 


F. 


13 


Right 


8 


7 


Yes 


2% 


Ya 


W» 


1 


Ya 


25 


M. 


15 


Right 


9 


6 


Yes 


4% 


9 


1*4 


X 


X 


26 


M. 


jo* 


Right 


9 


X 


No 


I/2 


% 


Ys 


M 


A 


27 


V. 


18 


Riaht 


9 


7 


No 


23/ 


X 


1 


■& 


Ya 


28 


M. 


18 


Right 


11 


10 


Yes 


2 


§ 


1 


X 


29 


V. 


15 


Lefi 


11 


7 


Yes 


3 


Vs 


K 


3/8 


30 


F. 


15 


Right 


11 


5 


Yes 


1 


Ya 


Ya 


% 


K 


31 


K 


15 


Right 


11% 


9K 


Yes 


3 




Y 


'4 


S 


32 


K. 


16 


Left 


1-1 


1 


No' 


VA 
VA 


« 


41 


33 


F. 


21 


Left 


17 


6 


Yes 


Va 


Va 


Average 


15 


j 


11 


6 


... 


2% 


v. 


1 


A 


v. 



— Measurements equal. x Measurements not taken. 

Measurements of the femur from the apex of the great trochanter to the knee-joint. Patella 
measured transversely. The cases are grouped according to the duration of disease and the 
averages are given separately for each group. 

General Symptoms of the Disease. Debility.— If the disease 
is sufficiently painful to cause loss of sleep and to affect the ap- 
petite, pallor and loss of flesh and strength may be expected. 
It must be borne in mind, however, that the patient may have 
been delicate long before the local tuberculous disease was ac- 
quired. At all events from the diagnostic standpoint at least, 
the local disease has no characteristic influence upon the general 



320 OB TH OPEBIC S UB GEB Y 

condition, and the appearance of perfect health is not at all 
unusual among patients with hip disease. 

Fever. — It is probable that a slight elevation of temperature 
might be detected in a large proportion of the patients, and in 
such cases actual appreciable fever often follows overexertion of 
injury. Fever, as a symptom of infected abscess in the later 
course of the disease, is, of course, of importance, but in the early 
stages of the disease the record of the temperature would be of 
but little diagnostic value. 

The History and the Method of Examination. — In consider- 
ing the differential diagnosis of tuberculous disease of the hip- 
joint one should keep its characteristics in mind. It is a chronic 
disease, in that the symptoms may have been present for weeks 
or months or even years before the patient is brought for treatment. 
It is a disease confined to a single joint, thus differing from rheu- 
matism and similar affections in which several joints are involved. 
It does not get well; thus it may be differentiated from injury 
and from the minor affections that simulate some of its symptoms. 
It causes a limp. It is accompanied by reflex muscular spasm, 
usually by a certain amount of deformity and by general atrophy 
of the muscles of the limb. 

The importance of the inheritance and of the personal history 
of the patient has been mentioned already in the consideration 
of Pott's disease. In recording the history in this as in all other 
chronic diseases of childhood one attempts to ascertain the ap- 
proximate duration of the pathological process rather than the 
duration of the more acute symptoms for which the patient has 
been brought for treatment. One asks, therefore, when the 
child was last perfectly well, and, bearing in mind the remission of 
symptoms, one asks if limp or pain had been noticed at any time 
before the more acute symptoms. In the history there is almost 
invariably mention of a fall, and one must ascertain whether the 
fall had any influence in the causation of the symptoms, remem- 
bering that the weakness and interference with function due to 
joint disease more often cause falls than falls cause joint disease. 
Physical Examination. — One begins the physical examination by 
the observation of the general condition of the patient, and notes 
the attitudes, and the character of the limp. The patient's cloth- 
ing is then entirely removed, that one may observe the contour 
of the part and the general influence of the affection upon the 
mechanism of the body. The patient is then placed on his back 
upon a table, with the limbs parallel to one another, so that their 



TUBERCULO US DISEA SE OF THE HIP-JOINT 321 

relative length and size may be observed. If the pelvis is level 
when the limbs are parallel, there can be no persistent abduction 
or adduction, for when the two anterior superior spines are on 
the same plane such distortion is always evident. If the lumbar 
spine and the popliteal surfaces of the knees rest on the 
table simultaneously it shows, too, that persistent flexion is absent. 
One next tests the function of the hip-joints, always beginning 
with the sound side for the purpose of comparison, and in order 
that the patient may become accustomed to the manipulation 
before the one suspected of disease is tested. Disease within 
a joint is accompanied by muscular spasm that limits motion in 
every direction, thus differing from other affections outside the 
joint that may limit its motion in one or more but not in all 
directions. 

One compares the flexion, abduction, adduction, and rotation 
of the limbs while the child lies upon its back; it is then turned 
upon its face to test for extension by holding the pelvis flat upon 
the table wi,th one hand while the thigh is gently elevated with 
the other (Fig. 16). The normal range of extension in child- 
hood is about twenty degrees backward from the line of the 
body, and limitation of this range is the earliest indication of the 
deformity of hip disease. It may precede the restriction of the 
extremes of motion in other directions, although this is unusual, 
and if this motion is unrestricted disease of the joint may be, 
practically speaking, excluded. The character of the reflex 
spasm that limits motion and the indications of discomfort when 
the limit has been reached have been described. 

Measurements. — The measurements of the limbs are then made. 
One first ascertains the actual length of the limbs by measur- 
ing from the anterior superior spines of the pelvis to the extremi- 
ties of the internal malleoli, actual shortening being of course 
absent in the early stage of the disease. The second measure- 
ment is from the umbilicus to show the amount of apparent 
shortening or lengthening that may be present if the limb is dis- 
torted. The actual length of the limbs, as measured from the 
anterior superior spines, is but slightly affected by tilting of the 
pelvis, but as the umbilicus is in the middle line of the body above 
the pelvis measurement from this point simply shows the actual 
distance to the malleoli. Persistent adduction causes compensa- 
tory obliquity of the pelvis; consequently the malleolus on the 
affected side is drawn upward or nearer to the umbilicus, while 
the other is carried downward to a corresponding distance 

21 



322 ORTHOPEDIC SURGERY 

(Fig. 208). If, then, the measurements from the umbilicus to the 
malleoli do not correspond relatively with those from the anterior 
superior spines, when the limbs are parallel and in the median 
line, it shows distortion; adduction, if the limb is relatively shorter, 
abduction, if it is relatively longer than is shown by the measure- 
ment from the anterior superior spine. It has been stated that 
the measurement from the anterior superior spine is not greatly 
change by distortion. It is, however, shortened by abduction, and 
it is correspondingly lengthened by adduction. This is explained as 
follows : When the limb is in the line of the body the trochanter 
is below the anterior superior spine from which the measurement 
is made. Abduction of the limb raises the trochanter toward 
the plane of the anterior superior spine, and consequently lessens 
the distance from this point to the extremity of the limb. Adduc- 
tion, on the contrary, lowers the trochanter and increases the 
distance between these two points. Ordinarily the variation 
from this source does not exceed half an inch. But if the dis- 
tortion is extreme the error must be corrected if the measure- 
ments are to be approximately accurate. Flexion of one thigh 
causes a tilting forward of the pelvis that lessens the distance 
between the anterior superior spine and the malleolus on both 
sides, although not to an equal degree. It is customary, there- 
fore, if the flexion is considerable, to raise the unaffected limb 
to the line of its fellow in making the comparative measurements, 
stating in the record that the limbs have been measured at the 
angle of the deformity and are therefore shortened. 

Method of Estimating the Degree of Distortion of 
the Limb. — As has been stated, when the pelvis is level, distor- 
tion of the limb is apparent, and the degree of distortion can be 
measured by the goniometer (Fig. 204) ; but it may be more easily 
ascertained by "Lovett's table." 1 This method is described 
by its author as follows: 

1 K. W. Lovett, Boston Medical and Surgical Journal, March 8, 188S. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 223 
Table I.— Distance between Anterior Superior Spines in Inches. 








3 


3K 


4 4% 


.1 


5% 


6 


6K 


7 


% 


8 


sy 2 


9 


9% 


10 


11 


12 


13 


bo 


' K 


5° 


4 c 


4° 


3° 


3° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


2° 


1° 


1° 


1° 


1° 


1° 


1 




% 
% 


10 
14 


| 8 
12 


7 
11 


6 

10 


5 
8 


5 

8 


4 

7 


4 

7 


4 
6 


4 
6 


4 
5 


4 
5 


4 
5 


3 

4 


3 

4 


3 

4 


3 
3 


2 
3 


CO 


1 


19 


17 


14 


13 


11 


10 


9 


9 


8 


7 


7 


7 


6 


6 


6 


5 


5 


4 


1 

1 

o3 


IK 


25 


21 


18 


16 


14 


13 


12 


11 


10 


9 


9 


8 


8 


7 


7 


7 


6 


6 


IK 


30 


25 


22 


19 


17 


15 


14 


13 


12 


12 


11 


10 


10 


9 


9 


8 


7 


7 


■=. 


1% 


36 


30 


26 


23 


20 


18 


17 


15 


14 


13 


13 


12 


11 


10 


10 


9 


8 


8 


"5 

9 


2 


42 


35 


30 


26 


23 


21 


19 


18 


16 


15 


14 


14 


13 


12 


13 


10 


10 


9 


a 

eg 


2K 




40 


34 


30 


26 


24 


21 


20 


19 


17 


16 


15 


14 


14 


13 


12 


11 


10 


9 


2K 






39 


34 


29 


27 


24 


22 


21 


19 


18 


17 


16 


15 


14 


13 


12 


11 




2K 








38 


32 


29 


27 


25 


23 


21 


20 


19 


18 


17 


16 


14 


13 


12 


3 








42 


35 


32 


29 


27 


25 


23 


22 


21 


19 


18 


18 


16 


14 


12 


rt 


3J4 










39 


36 


32 


30 


27 


26 


25 


22 


21 


20 


19 


17 


15 


14 


0} 

o 


3K 










... 


40 


35 


33 


30 


28 


26 


24 


23 


22 


21 


19 


17 


16 


1 

P 


3^ 














38 


35 


32 


30 


28 


26 


25 


23 


22 


20 


18 


17 


, 4 














42 


38 


35 


32 


30 


28 


26 


25 


23 


21 


19 


18 



"To measure by this method the patient is made to lie straight 
with the legs parallel. Real shortening is measured with the 
ordinary tape measure, and apparent shortening is obtained in 
the same way. It may be repeated that real or bony shortening 
is measured from the anterior superior iliac spines to each mal- 
leolus, and that practical shortening is found by a measurement 
taken from the umbilicus to each malleolus. The difference in 
inches between the two kinds of shortening is seen at a glance. 
The only additional measurement necessary is the distance be- 
tween the anterior superior spines, which is taken with the tape. 
Turning now to the table : if the line which represents the amount 
of difference in inches between the real and apparent shorten- 
ing is followed until it intersects the line which represents the 
pelvic breadth, the angle of deformity will be found in degrees 
where they meet. If the practical shortening is greater than 
the real shortening, the diseased leg is adducted; if less than real 
shortening, it is abducted. Take an example: Length (from 
anterior superior spine) of right leg, 23; left leg, 22 J; length 
(from umbilicus) of right leg, 25; left leg, 23; real shortening, 
J inch; apparent shortening, 2 inches; difference between 
real and practical shortening, 1J inches; pelvic measurement, 



324 ORTHOPEDIC SURGERY 

7 inches. If we follow the line for 1J inches until it intersects 
the line for pelvic breadth of 7 inches, we find 12 degrees to be the 
angular deformity, as the practical shortening is greater than the 
real, it is 12 degrees of adduction of the left leg. If apparent 
lengthening is present its amount should be added to the amount 
of actual shortening." 

If flexion is present the degree may be ascertained by raising 
the flexed limb until the lumbar spine touches the table, when the 
angle formed by the thigh with the body may be measured with 
the goniometer (Fig. 203), or its degree may be ascertained by 
Kingsley's table. 

"The patient lies upon a table flat on his back and the surgeon 
flexes the diseased leg, raising it by the foot until the lumbar 




A C 

Kingsley's method of estimating flexion. 

vertebrae touch the table, showing that the pelvis is in the correct 
position. The leg is then held for a minute at that angle, the 
knee being extended, while the surgeon measures off two feet on 
the outside of the leg with a tape measure, one end of which is 
held on the table, so that the tape measure follows the line of 
the leg (A B). From this point on the leg (B) where the two 
feet reach by the tape measure one measures perpendicularly 
to the table (B C), and the number of inches in the line B C can 
be read as degrees of flexion of the thigh by consulting Table II. 
For instance, if the distance between the point on the leg and the 
table is 12J inches it represents 31 degrees of flexion deformity 
of the thigh. 



TUBERCULOUS DISEASE OF THE HIP- JOINT 325 

Table II.i 



0.5 inches. 


1° 


6.5 inches. 


16° 


12. 5 inches. 


31° 


18.5 inches. 50° 


1.0 


2 


7.0 


17 


13.0 


33 


19.0 


52 


1.5 


3 


7.5 


19 


13.5 


34 


19.5 


54 


2.0 


4 


8.0 


20 


14.0 


36 


20.0 


56 


2.5 


6 


8.5 " 


21 


14.5 


37 


20.5 


58 


3.0 


7 


9.0 


22 


15.0 


39 


21.0 


60 


3.5 


9 


9 5 


24 


15.5 


40 


21.5 


63 


4.0 


10 


10.0 


25 


16.0 


42 


22.0 


67 


4.5 " 


11 


10.5 


27 


16.5 


43 


22.5 


70 


5.0 


12 


11.0 


28 


17.0 


45 


23.0 


75 


5.5 


14 


11.5 


29 


17.5 


47 


23.5 


80 


6.0 


15 


12.0 


30 


18.0 


48 


24.0 


90 



"If the leg is so short that it is impracticable to measure off 
twenty-four inches one can measure twelve inches; ascertain from 
here the distance to the surface on which the patient is lying in a 
perpendicular line in the same way, then doubling this distance 
and looking in the table as before the amount of flexion is found." 

Atrophy. — The circumference of the thighs, the knees, and 
the calves is then measured at corresponding points to test for 
atrophy or for other irregularities that may require explanation. 
The atrophy of joint disease affects the entire limb, and it is an 
unfailing symptom except in the earliest stage of the disease. It 
might be concealed in the thigh by a deep abscess, but it would 
still appear in the calf. 

Local Signs of Disease. — The hip-joint is so concealed by the 
overlying tissues that the local sensitiveness and swelling which 
usually accompany similar disease at the knee and ankle are often 
absent. Firm pressure before or behind the trochanter, or over 
the head of the femur usually causes some discomfort, however. 
In many instances a peculiar resistance of the deeper parts, caused 
by infiltration of the tissues that cover the joint, is evident on 
palpation; and swelling about the joint and thigh, caused by 
effusion or by deep abscess, is not unusual when patients are first 
brought for treatment. Sensitiveness of the skin and local eleva- 
tion of the temperature may be present if the disease is acute, 
particularly if an abscess is on the point of breaking through the 
skin. 

The diagnosis of tuberculous disease of the hip, except, per- 
haps, in the stage of inception, is in most instances evident on 
a systematic examination, such as has been outlined, and it is 
probable that errors are due rather to a neglect of such examina- 
tion than to any particular obscurity that the ordinary case may 
offer. 



G. L. Kingsley, Boston Medical and Surgical Journal, July 5, 1888. 



326 OR THOPEDIC S UB GEE Y 

Diagnosis. Local Irritation. — Strains of the muscles of the 
thigh, enlarged glands in the groin, irritation or disease of the 
genitals may, in infancy or early childhood, cause persistent flex- 
ion of the thigh and pain on motion. Simple muscular strains 
quickly recover, while the inflamed glands and other causes 
of local irritation are usually apparent on inspection. 

"Growing Pains." — So-called growing pain is probably due in 
many instances to strain of the muscles or to injury about the 
hip; in other cases it may be explained by rheumatism. 

Local Injury. — It would appear that injury, often of a trivial 
character, may cause congestion in the neighborhood of the 
epiphyseal cartilage of the head of the femur and that injury of 
this character in delicate children may be a predisposing cause 
of tuberculous disease. Such a sensitive condition causes a 
limp, pain, or discomfort on overuse and restriction of motion. 
These symptoms may last a few days or a few weeks; they may 
disappear and recur from time to time, and they can only be 
distinguished from those of incipient disease by continued obser- 
vation. (See also Fracture of the Neck of the Femur.) 

Synovitis. — In certain cases of injury synovial effusion may be 
present, although this is unusual. 

In the cases in which the functional disturbances is caused by 
local irritation or by slight strain the symptoms are of sudden 
onset and are evidently of trivial importance, but if there is any 
doubt as to the diagnosis the hip should be bandaged and the 
patient should remain in bed or at rest until the complete sub- 
sidence of the symptoms or their persistence makes the diagnosis 
clear. 

Anterior Poliomyelitis. — Occasionally anterior poliomyelitis may 
be accompanied by pain on motion in the affected limb before 
paralysis is apparent, but in a few days at most the diagnosis is 
evident. 

Rheumatism. — Rheumatism is usually of sudden onset. It is 
almost always migratory in character and it is accompanied by 
fever. If it were confined to a single joint, as is sometimes the 
case in young children, and if the history were obscure, the diag- 
nosis might be uncertain for a time. In such cases appropriate 
remedies should, of course, be employed. 

Scurvy. — This is also an affection whose symptoms are general 
in character. It is, therefore, more likely to be confounded with 
rheumatism than with a local disease. In rare instances one 
joint only appears to be involved, but this is, as a rule, the knee 



T UBER CULOUS DISEA SE OF THE HIP- J OINT 327 

rather than the hip. Pain on motion of the limbs, in an infant 
artificially fed, always -suggests scurvy. 

Infectious Arthritis and Epiphysitis. — Mild forms of infectious 
arthritis may follow scarlet fever, diphtheria, pneumonia, and, in 
a more severe and destructive form, typhoid fever. As a rule, 
however, several joints are involved, and, although the affection 
might be mistaken for rheumatism, it could hardly be confounded 
with local tuberculous disease. 

Infectious arthritis or epiphysitis of the hip-joint is not un- 
common in early infancy. It is of sudden onset, accompanied by 
high fever and by constitutional disturbance. These symptoms, 
together with the local heat and swelling, caused by the rapid 
formation of pus, show the character of the affection and indicate 
the necessity for prompt surgical intervention. 

Gonorrhoeal arthritis is a form of joint infection that in adult 
age may resemble somewhat the subacute form of tuberculous dis- 
ease. As a rule, however, it is of sudden onset and is evidently 
associated with the local disease. 

Extra-articular Disease. — Disease in the neighborhood of the 
joint, as of the trochanter or of the tuberosity of the ischium, 
may cause a limp and pain; in most instances the local sensi- 
tiveness and local swelling indicate the seat of the disease, while 
motion of the joint is limited only in the directions that cause 
tension on the sensitive parts. 

Osteoarthritis of the Hip. — Osteoarthritis at the hip-joint may be 
mistaken for tuberculous disease, and at times the diagnosis may be 
obscure. This is, however, a disease of adult life, and it is in most 
instances accompanied by other evidences of a general affection. 
The general form of rheumatoid arthritis in childhood may begin 
in a single joint. The pain may be severe, and there may be 
muscular spasm and distortion of the limb. The diagnosis is 
usually made clear by the successive involvement of other 
joints. 

Pott's Disease. — Disease of the lumbar region of the spine before 
the stage of deformity, when the pain is referred to the lower 
extremities, and in which unilateral psoas contraction causes a 
limp, is often mistaken for hip disease, although the distinc- 
tion between them is very clear. Psoas contraction limits ex- 
tension only; all the other movements of the limb are unrestrained. 
The muscular spasm, of which the psoas contraction is a part, 
is a spasm of the muscles of the spine about the seat of disease, 
as is evident on examination. Other causes of psoas contraction 



328 ORTHOPEDIC SURGERY 

have been mentioned in the consideration of Pott's disease. In 
exceptional cases active disease of the lower region of the spine 
in young children may set up spasm of the muscles about the 
hip, and vice versa, so that it may be impossible to decide at the 
first examination whether the irritation is in the hip or in the 
spine or in both. 

Sacroiliac Disease. — Disease of the sacroiliac junction is very 
uncommon in childhood. The symptoms and the attitude re- 
semble sciatica rather than hip disease. There is local pain at 
the seat of disease upon lateral pressure on the pelvis, and if the 
pelvis be fixed the motion at the hip-joint will be found to be 
free and painless. 

Pelvic Disease. — Localized disease of one of the pelvic bones 
may cause discomfort and a limp. The cause of the symptoms is 
usually explained by the appearance of an abscess. 

Disease of the Bursse about the Joint. — Inflammation of the 
bursse about the hip may cause local swelling and sensitiveness, 
a limp and limitation of motion in certain directions, but the 
characteristic muscular spasm of hip disease is absent. Iliopsoas 
bursitis forms a fluctuating swelling in Scarpa's space, gluteal 
bursitis a localized swelling of the buttock. 

Coxa Vara. — Depression of the neck of the femur is a simple 
deformity. It causes a limp and more or less discomfort, but 
the character of the deformity, shown by the actual shortening 
and by the elevation and prominence of the trochanter dis- 
tinguishes it from hip disease, in which these are late symp- 
toms. In coxa vara there is unequal limitation of motion, 
abduction, flexion, and inward rotation being somewhat restricted, 
while extension, the first motion limited in hip disease, is as a 
rule not affected. 

Fracture of the Neck of the Femur in Childhood or Traumatic 
Coxa Vara. — Fracture of the neck of the femur in childhood is 
often of what may be termed the green-stick variety, a depression 
of the neck of the femur without actual separation of the frag- 
ments; and in many instances the patients are able to walk about 
within a short time after the accident. In such cases the limp 
and discomfort, attended during the stage of repair by a certain 
degree of muscular spasm, are often mistaken for the symptoms 
of disease. The history of the accident followed by immediate 
disability, the shortening and the elevation of the trochanter 
are usually sufficient to exclude disease. In doubtful cases the 
z-ray may be required to establish the diagnosis. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 329 

Congenital Dislocation of the Hip. — Congenital dislocation of 
the hip causes a limp, but it is a limp that has existed since the 
child began to walk and that is unaccompanied by the symptoms 
of disease. The nature of the disability should be apparent on 
examination. 

Hysterical Joint. — In hysterical subjects a limp, apparent pain, 
and distortion of the limb, often following slight injury, may 
simulate disease. Hysteria is very uncommon at the period of life 
in which tuberculous disease is most frequent. Patients of this 
class usually present other symptoms of hysteria; the characteristic 
signs of disease, muscular spasm and atrophy, are absent while 
while the apparent discomfort and the vouluntary distortion are 
quite out of proportion to the physical evidences of injury or 
disease. 

The X-ray in Diagnosis. — Roentgen pictures are of far more 
value in demonstrating deformity than in establishing early diag- 
nosis of disease, especially of the hip in early childhood, when so 
large a part of the extremity of the femur is cartilaginous; the 
only constant indications of disease being atrophy of the shaft 
of the femur and a blurred outline "fogginess" of the parts 
actually involved. The pictures are of value, however, in show- 
ing the destructive effect of the disease on the head of the femur 
or acetabulum, and thus giving one a clearer conception of the 
actual condition of the joint than would be possible otherwise 
(Fig. 209). In older subjects it may be possible to demonstrate 
the presence of disease in the interior of the bone by this means, 
but in any event Roentgen pictures are of value only when in- 
terpreted by knowledge of the physical signs. 

Method of Recording a Case.— The record should contain the 
general history of the patient together with an account of the 
more important symptoms, and of the treatment that may have 
been employed. The physical examination should include the 
weight and height for comparison with the normal standard, and 
as a basis on which to judge the future progress of the case. Then 
follows a brief description of the gait and attitude, of the char- 
acter of the distortion, if it be present, and of the changes from 
the normal contour. If restriction of motion is present, its causes 
are stated if possible; whether, for example, it is due to simple 
muscular spasm or in part to adhesions and contractions. 

The presence or absence of heat and swelling, of abscesses, 
sinuses, and the like is indicated. If there is actual shortening 
of the limb its causes and distribution should be stated; whether 



330 ORTHOPEDIC SURGERY 

it is the result of simple retardation of growth or of elevation of 
the trochanter, as may be ascertained by Nelaton's line and by 
Bryant's triangle. 

If the elevation is due in great part to the enlargement of the 
acetabulum, while the upper extremity of the femur remains 
fairly normal in shape, the projection of the trochanter is more 
noticeable, and the distortion of the limb in adduction is greater, 
than when the elevation is the result of destruction of the head 
of the bone. In this class of cases Roentgen pictures are of ser- 
vice in showing the actual condition of the joint (Fig. 210). 

A condensed account of the more important points in the 
physical examination may be presented by the formula used at 
the Hospital for Ruptured and Crippled, as follows: R.A. — R.U. 
— R.T.— R.K.— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A.— L.U.— 
L.T.— L.K.— L.C. 

"A" indicates the distance from the anterior superior spines 
to the internal malleoli. 

"U," from the umbilicus to the same points. 

"T," "K," and "C," the circumferences of the limb at the 
thighs, knees, and calves. 

"A.G.E.," indicates the angle of greatest extension. 

"A.G.F.," the angle of greatest flexion. Thus the restriction 
of the range of anteroposterior motion at the hip is shown by 
these measurements. 

"A.S.P," is the transverse diameter of the pelvis between the 
anterior superior spines, the measurement required in Lovett's 
table for ascertaining the degree of lateral distortion. 

If, for example, the record reads: 

R.A. m— R.U. 20 — R.T. 11 — R.K. 8|— R.C. 7f— A.G.E. 1.50— A.S.P. 7 
L.A. 18*— L.U. 2H— L.T. 10J— L.K. 8^— L.C. 7J— A.G.F. 90 

it would show at a glance that there was no real shortening, that 
the limb was abducted because of the one and a quarter inches 
of apparent lengthening, according to the table, the equivalent 
of 10 degrees of abduction. It would show that there was per- 
manent flexion of 30 degrees and a range of motion between 
the limits of flexion and extension of 60 degrees, as compared 
with the normal of about 130 degrees. 

The following details of the one thousand cases of hip disease 
investigated for me by Ashley are of interest as illustrating the 
character of the cases treated at the Hospital for Ruptured and 
Crippled : 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



331 



The Duration of Disease when Treatment was Begun. 



Three months or less . 


. 396 


Three to six months 


. 170 


Six months to one year 


. 80 


One year 


. 124 


Two years 


. 75 


Three years 


. 29 



Four years 21 

Five years 17 

From five to ten years . . 35 

From ten to forty years . . 16 

Not stated 37 

1000 



The Degree op Deformity Present on First Examination. 



No deformity . . . 


. 130 


55 degrees of flexion 


. 10 


5 degrees of flexion 


. 44 


60 


26 


10 




. 89 


65 


8 


15 




69 


70 


22 


20 




. 118 


75 


2 


25 




. 32 


80 . . 


11 


30 




. 135 


85 " " " . . 


1 


35 




. 56 


90 . ; 


12 


40 




. 70 


More than 90 ... . 


1 


45 
50 


Restriction o 


. 41 
. 68 

f Motion 


Not stated 

at First Examination. 


55 

1000 


Normal motion . 






. 30 


A range 


of motion through 


105 degrees 




. 14 


•• 


.. 


90 " 




. 65 






75 " 




. 49 






60 " 




. 95 






45 " 




. 67 


" 




30 " 




. 112 


" 


.. 


15 " 
5 " 






•• 




. 157 








. 147 


Not stated .... 






. 169 



Attitude of the Limb at First Examination. 

Flexion to a greater or less degree 814 

No flexion 130 

Not stated 56 



Other Distortions Recorded. 

Abduction 254 

Adduction 167 

External rotation 166 

Internal " 58 

Actual Shortening when Treatment was Begun. 



M inch 129 

% 
1 

IK 
IH 
IK 
2 



129 


2}4 inches 


143 


2)4 " 


22 


2% " 


51 


3 


9 


3H " 


16 


3M " 


6 


9Y2 " 


21 





Shortening absent or not stated in 
Abscess not present in ... 



332 ORTHOPEDIC SURGERY 

Treatment. — The principles that should govern the treatment 
of a disease are best indicated by the study of cases that have 
received no treatment, and that show, therefore, the natural 
history of the affection. 

A characteristic case of tuberculous disease of the hip-joint 
begins insidiously. It causes a slight limp and at times discom- 
fort and pain. In the early stage of the disease there is a slight 
flexion of the limb, usually combined with abduction, the instinc- 
tive assumption of the attitude of rest. As the disease progresses 
the limb becomes less capable of performing its proper function; 
the range of painless motion becomes more and more restricted, 
and the attitude changes to one of increased flexion and adduction, 
the attitude in which the limb is best protected from injury and 
in which it is least capable of performing its share of normal 
work. Pain is more constant, abscess is often present, and the 
constitutional effects of a depressing disease may be apparent. 
This progression of symptoms and attitudes is so fairly constant 
that hip disease was in former times often divided into stages corre- 
sponding to these early and later manifestations of its effects. 
When the limb has reached the position of greatest protection, 
when motion which at first was limited only by the involuntary 
spasm of the muscles that are now atrophied, is restricted by 
adhesions and contractions, pain often ceases to be a trouble- 
some symptom, the general health improves, and effective repair 
begins. During the progressive stage erosion of the opposing 
surfaces of the joint has advanced, always more rapidly at the 
points of mutual pressure and friction, the upper and inner sur- 
face of the head of the femur and the upper margin of the acetabu- 
lum, and here the disease remains active while repair progresses 
at the points which have been relieved from irritation. Thus 
in many instances the upper margin of the acetabulum is de- 
stroyed and a subluxation of the femur takes place (Fig. 198), a 
displacement favored by the attitude of flexion and adduction, 
and induced by muscular spasm and by pressure upon the limb. 
In some instances there is complete displacement, and when the 
diseased parts are thus separated from one another by this form 
of pathological dislocation relief of symptoms and practical re- 
covery may quickly follow, although sinuses leading to areas 
of local disease or to fragments of necrosed bone may persist for 
many years. 

Nature's cure of hip disease implies recovery with a shortened 
and distorted limb, a final result which is common enough even 






TUBERCULOUS DISEASE OF-THE HIP-JOINT 333 

when treatment has been employed to explain the popular con- 
ception of what hip disease entails (Fig. 207). 

As has been stated, it was customary in former years, when 
treatment was neglected or less efficient than at the present time, 
to speak of a first, second, and third stage of hip disease, corre- 
sponding to the character of the deformity, but early or later 
stage as used by the writer refers to the inception and progression 
of the local pathological process, not to the distortion of the limb. 

There are many cases of hip disease in which the primary focus 
in the head of the bone is so limited in extent that perfect func- 
tional cure may result under any form of treatment, or non-treat- 
ment even. And there are others in which the disease is of such 
a destructive character that the result must be disastrous in spite 
of treatment. But there can be no doubt that by early diagnosis 
and by efficient protection prolonged suffering may be prevented, 
that useful function may be preserved, which would otherwise 
have been lost. 

The object of treatment is to prevent the symptoms and the 
effects of the disease that have been outlined as characteristic of 
the untreated cases. To relieve the pain that depresses the 
vitality of the patient. To relieve the muscular spasm that 
induces distortion of the limb, and that stimulates the activity 
of the destructive process by increasing the pressure and friction 
of the diseased surfaces of the opposing bones. To correct and 
to prevent deformity and to prevent, as far as may be by lessen- 
ing the pressure and by restraining motion, the upward dis- 
placement of the femur that causes irremediable distortion. 

There are cases in which radical removal of the diseased parts 
may be indicated, and there are times when acute symptoms may 
require absolute rest of the patient. But in the management of 
a chronic tuberculous disease, throughout the period of years that 
may elapse before cure is accomplished, the primary require- 
ments of the treatment that have been indicated must be met, as 
far as may be, by appliances that allow exercise in the open air. 

Mechanical Treatment. — The most effective treatment of a dis- 
eased joint is that which assures it the most perfect rest and pro- 
tection. If the disease is in the earliest stage and confined to the 
interior of the bone, rest offers the most favorable condition for 
repair and for preservation of the joint. If the disease is fur- 
ther advanced, complete relief of function affords an opportunity 
for nature to check its progress and to preserve, it may be, a 
part of the joint from invasion. If the joint is already involved, 



334 ORTHOPEDIC SURGERY 

rest offers the best opportunity for repair by preventing friction 
that stimulates the progress of the disease and increases its de- 
structive effects. Whatever checks or retards the progress of 
the disease correspondingly relieves its symptoms and prevents 
constitutional depression and thus preserves the vital resistance, 
both local and general, upon which the cure of the disease ulti- 
mately depends. Rest of a diseased joint of the lower extremity 
necessitates splinting, stilting and traction. 

Splinting naturally signifies the fixation that may be attained 
by the application of a splint, extending a sufficient distance on 
either side of the part to be fixed. 

Stilting — the elevation of the foot from the ground so that 
jar and pressure on the diseased articulation may be removed. 

Traction — a sufficient force exerted upon the limb to over- 
come and to control the spasmodic action of the muscles. 

The knee-joint, the junction of two levers of similar size and 
function, may be easily controlled or placed at rest by means of 
apparatus. But the hip-joint is a ball and socket joint which 
allows free motion in many directions, and, being the junction of 
the body and the limb, two segments of different size and func- 
tion, it is especially difficult to control. For this reason as much 
as any other, perhaps, the treatment of hip disease has been 
the subject of controversy for many years. And even at the pre- 
sent time one can hardly describe the treatment of hip disease 
adequately without contrasting the methods of treatment that 
are in common use. 

Such an exposition should begin naturally with a description 
of what has long been known as the American treatment, in 
which traction has always occupied the most important place. 

The Traction Hip Splint. — The traction hip splint consists of a 
pelvic band and an upright. The pelvic band is made of sheet 
steel about an eighth of an inch in thickness and one and one- 
eighth inches in width, sufficiently strong to support the weight 
of the body without yielding, bent into a U-shape to conform to 
the pelvis, but wide enough to cause no anteroposterior pressure. 
As Taylor puts it, there should be room enough for the pelvis to 
move freely in it. This band embraces about three-quarters of 
the pelvis at a point just above the trochanter. It is covered 
with leather, and is provided with a strap to complete the cir- 
cumference. Upon the pelvic band four buckles are placed 
for the attachment of the perineal bands. The two buckles on the 
front band are placed directly above the attachments of the ad- 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



335 



ductor muscles, on either side of the genitals. Behind, the buckles 
are placed much farther apart, somewhat to the outer side of 
each ischial tuberosity, upon which, in great part, the weight 
of the body is to be supported. The pelvic band is bolted firmly 
to the upright at a slight inclination, corresponding to the inclina- 
tion of the pelvis. The upright extends from the top of the tro- 
chanter to two or more inches below the sole of the foot. It may 
be made in one piece or in two sections overlapped and attached 




The traction hip splint, with overlapping upright and windlass, used at the Boston 
Children's Hospital. (Bradford and Lovett.) 

to one another by screws, to allow for adjustment (Fig. 213). 
It is turned inward at a right angle below the foot and is shod 
with leather or rubber. The foot-piece may be provided with 
a windlass (Fig. 212), or the traction may be made by simple 
straps attached on either side (Fig. 218). At about the middle 
of the upright is placed a support of light steel, which is provided 
with a broad leather strap for the purpose of fixing the thigh to 
the brace and supporting the knee. In some braces a second 
similar support is placed at the upper part of the stem; in others 



336 OB THOPEDIG S UB GEB Y 

the knee is supported only by a broad leather pad which covers 
its inner surface and is attached to a cross-piece on the upright 
by straps, as in the Taylor brace. In the Taylor brace, which 
has served as a model for all similar appliances, the upright is a 
steel tube into which slides a rod, supporting the foot part of the 
brace, the two parts being joined with a rack-and-pinion attach- 
ment and lock, so that the brace may be lengthened or shortened 
by means of a key (Fig. 217). 

Traction Plasters. — Traction upon the limb is made by adhesive 
plaster, preferably that known as moleskin (yellow) plaster, which 
is far less irritating to the skin than rubber plaster. 

These plasters should be cut into a shape corresponding to the 
lateral aspect of the thigh and leg, thus: wide above and narrow 
below, reaching from the trochanter on the outer, and from the 
pubes on the inner side, to the malleoli (Fig. 238). The lower 
ends are reinforced by a second layer of plaster and to them 
buckles are attached. The plasters are then applied to the limb 
and are held in place by a bandage which is smoothly applied 
and then sewed, to prevent disarrangement. The object of the 
bandage is primarily to assure the adhesion of the plaster and 
secondarily to keep it clean. It can be replaced by a properly 
fitted covering of stockinette or by a stocking leg. 

Another method of applying the plaster, designed to obtain 
a better hold upon the limb, is that devised by Taylor, and de- 
scribed by him as follows: "The first important object is to 
seize the leg in such a manner as to exert against it an unyielding 
force. This should be done in such a manner as will not interfere 
with the circulation, nor injure the knee, by unequal strain either 
below or above it. In other words, the whole leg should be grasped 
in such a manner that the knee will be supported. It may be 
done as follows: A strip of adhesive plaster, long enough to reach 
from the waist to the foot, and from three to five inches wide at 
the upper and about one-third that width at the lower end, is taken 
and cut into five tails, as shown in the accompanying illustration 
(Fig. 215). A piece from four to six inches long is cut from the 
centre tail and added to the lower end to strengthen it; and, if 
the patient be strong, one or two more pieces are laid on the same 
place, where a buckle is attached. Two similar straps are pre- 
pared, one for the inside and one for the outside of the leg, and 
laid against the lateral aspects of the leg, the ends with the buckles 
beginning about two inches above the internal and external mal- 
leoli, and the centre tails reaching the entire length of the leg 



TUBERCULOUS DISEASE OF THE HIP-JOINT 337 

and thigh, to the perineum inside and the trochanter on the outside. 
The lower strips or tails are then wound spirally around the leg 
to the pelvis and afterward the other two pairs of tails, which are 
cut down to just above the knee, are also wound about the thigh 
in the same manner. When completed the thigh is involved in 
a network of strips of adhesive plaster, which act equally and 
without pressure on the whole surface. The leg has about one- 





C. F. Taylor's method of applying adhesive plaster. 

fourth of the attachments, and the thigh three-fourths, which is 
found to be the right proportion to protect the knee equally from 
compression or strain. A few turns of the roller bandage are 
then made around the ankle just under the lower ends of the straps, 
which serves as a protection to the flesh under the buckles, and 
then it is continued over the straps on the whole leg. Thus 
prepared, the patient is ready for the splint" (Fig. 216). 

At the Boston Children's Hospital the lower ends of the ad- 
hesive straps terminate in tapes that extend below the foot for 

22 



338 



ORTHOPEDIC SURGE BY 



attachment to the windlass, which is used with the cheaper form 
of brace. 

Perineal Bands. — Perineal bands are made by covering a firm, 
wide, unyielding band of webbing with several folds of blanket 
or similar material and then binding it smoothly with canton 
flannel. These are made in different 
lengths and sizes, as may be required. 
The "High Shoe."— The best and 
lightest material for raising the shoe 
worn on the sound foot to corres- 
pond with the brace is cork, and the 
ordinary thickness is two and a half 
inches. A good and cheap substitute 
may be made of light wood provided 
with a leather sole, and in certain 
cases a patten of metal may be used. 
The Application of the Traction Hip 
Splint. — The traction brace is ap- 
plied in the following manner: 

The patient lying upon his back, 
the pelvic band is first adjusted and 
is strapped about the body. The 
perineal supports are then drawn 
firmly into place so that pressure on 
the upright does not move the pelvic 
band from its proper position, just 
above the trochanter. The brace is 
then pushed upward against the re- 
sistance of the perineal bands, while 
the limb is at the same time drawn 
downward and is fixed by attaching 
the straps to the buckles at the ends 
of the adhesive plasters. If the brace 
is provided with a windlass or ratchet, further traction is applied 
to the point of tolerance by means of the key, care being taken in 
adjusting the brace that it does not project so far below the foot as 
to more than equal the extra length provided by the high shoe on 
the sound side. The knee band is then adjusted and in many 
instances a strap is placed about the ankle and the brace to assure 
greater security. The shoe is then put on, the leg clothing is 
drawn over the brace, and the patient is allowed to stand. If in 
walking the patient is inclined to tilt the foot downward and to 




The original traction hip brace pro- 
vided with an abduction screw and a 
strap to regulate the inclination of 
the pelvic band on the upright. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



339 



bear the weight on the toe, a strap is attached to the middle of 
the foot-piece and fastened to a buckle on the heel of the shoe 
with sufficient tension to hold the foot in the horizontal position. 
By means of this brace the weight is borne entirely upon the 
perineal bands; thus the joint is relieved from pressure and from 
jar. The perineal bands should be accurately adjusted to pass 
upward in front, parallel to one another on either side of the 



a 



The Judson brace. This has but one perineal band, and the upright is bolted firmly 
to the pelvic band. 

genitals, in order to avoid pressure on the inner borders of the 
thigh; while behind they turn diagonally outward in order to 
pass over the tuberosities, which are best adapted for weight 
bearing. 

In the original Taylor hip brace the pelvic band is bolted to 
the upright in a manner to allow anteroposterior motion, and the 
inclination of the pelvic band is regulated by a strap attached 



340 ORTHOPEDIC SURGERY 

to the upright for better adjustment (Fig. 217), when the limb 
is flexed to a marked degree. This brace has been modified by 
Taylor by shortening and changing the shape of the pelvic band 
for the use of but one perineal support (Fig. 252); and a similar 
form of brace is used by Judson. The shortened pelvic band 
lessens the restraint of the brace upon the motion of the limb, 
and seems to offer little compensating advantage. 

Before the traction brace is used in ambulatory treatment, 
distortion of the limb, if it be present, should be reduced ; or if the 
disease is particularly acute, preliminary rest in bed until the 
subsidence of the symptoms is advisable. 

The Reduction of Deformity by Means of the Traction Brace. — The 
patient lies in bed upon a firm mattress; the distorted limb is 
then raised to slightly more than a sufficient angle to relax the 




The reduction of flexion by means of the traction hip splint. (C. F. Taylor.) 

contracted muscles and to straighten the lumbar lordosis; it is 
then abducted or adducted if necessary until the level of the 
pelvis is restored. The pelvic band is made to conform to this 
greater relative inclination of the pelvis by lengthening the pos- 
terior strap; the brace is then applied, the limb being held in 
the attitude of deformity by a sling or support (Fig. 219), and 
as much traction as the patient can tolerate is exerted by length- 
ening the upright. The direct traction exerted by the brace may 
be reinforced by means of a cord running over a pulley at the 
foot of the bed, in the line of the brace, to which a weight of ten 
or more pounds (Fig. 220) is attached. Thus the pressure of 
the perineal bands is somewhat lessened. Efficient traction will 
quickly reduce recent deformity caused by muscular contraction, 
and as this is lessened the position of the limb is correspondingly 
changed until it lies extended and parallel with its fellow. If 



TUBERCULOUS DISEASE OF THE HIP-JOINT 341 

adduction be combined with flexion the perineal band on the 
side opposite to the disease is tightened from time to time, or a 
direct push against the opposite adductor region is exerted by 
means of a bar attached to the brace opposite the knee (Fig. 
248). In ordinary cases the deformity may be reduced by this 
means in from two to six weeks. 

The brace should be worn day and night. The perineal bands 
may be loosened at times to allow for bathing the skin with alcohol 
and for powdering, in order that the skin may be kept dry; but 
at such times, if the disease be acute, manual traction should be 
made until the brace has been readjusted. The adhesive plasters, 
if of moleskin, may often remain in position for three months 
or longer. When they are removed the limb is gently bathed 
with alcohol. Excoriations are unusual unless rubber plaster 




A method of reducing flexion in hip disease. The brace is adjusted to the angle of de- 
formity, and in addition to the direct traction of the apparatus weights are attached to the 
brace itself. In the illustration counter-traction, by means of perineal bands attached to 
the head of the bed, is shown. 

is used. If the skin is abraded the part should be powdered 
with boracic acid and protected from the plaster by a layer of 
gauze. 

The Relative Efficiency of the Traction Hip Splint. — 
In analyzing the action of this brace it is evident at once that it 
is thoroughly effective as a stilt. It is effective as a traction 
appliance, in the sense of relieving muscular tension, in direct 
proportion to the care that is exercised in its adjustment. Trac- 
tion by this appliance may be made constant and effective, even 
to the point of practical fixation while the patient is in bed, or 
when crutches are used, in ambulatory treatment. But when 
the apparatus is used as a walking brace, as was designed by its 
inventor, constant traction is not exerted, for the traction straps 
alternately relax and tighten when the weight of the body falls 



342 ORTHOPEDIC SURGERY 

upon and leaves the brace in walking. When the brace is off 
the ground the joint is subjected to the traction that the brace 
exerts, plus its weight, as contrasted with cessation of traction 
and the relief from the weight when the brace supports the body 
at the alternate step. Thus the critics of the brace assert, in 
somewhat exaggerated language, that it exercises a pumping 
action on the joint. As a matter of fact, the observation of patients 
under treatment by this method will show that little actual trac- 
tion is exerted in the ordinary cases; that the so-called traction 
really serves principally for the adjustment of the brace, which 
by its weight exercises a certain intermittent traction during 
locomotion. The hold of the encircling band upon the pelvis 
assures a considerable restriction of motion; but whatever splint- 
ing action it may have depends upon the degree of traction, which 
is never effective enough, however, to prevent a certain amount 
of motion; according to the experiments of Lovett, a range of at 
least 35 degrees even when the brace is properly adjusted. 1 

The fact must be borne in mind that the traction hip splint 
was not intended to be a fixation or splinting appliance. On the 
contrary, Davis, its inventor; Taylor, who changed it into a practi- 
cable form, and Sayre, who further modified it, each believed 
that motion, except when the joint was fixed by muscular spasm, 
was desirable, and the brace was designed to permit it, the trac- 
tion preventing friction. 

Motion without friction in this sense would seem to imply the 
actual separation of the femur from the acetabulum, or distrac- 
tion as distinct from traction. That actual distraction is pos- 
sible at the hip-joint both in health and disease is proved by 
the experiments of Brackett 2 and by those of Bradford and 
Lovett. These experiments show that a traction force from ten 
to twenty pounds is required to cause one-eighth to one-quarter 
of an inch of actual lengthening of the limb, even in childhood. 
It is, therefore, to say the least, unlikely that the feeble and inter- 
mittent traction exerted by a hip splint, when used as an ambu- 
latory support, can be sufficient to separate the bones from one 
another and thus to allow motion without friction as was 
originally claimed for this apparatus. 

At the present time the theory that motion of a joint which is 
actually diseased is of benefit, or even that it is harmless, has 

l R. W. Lovett, New York Medical Journal, August 8, 1891. 

'- Brackett, Transactions American Orthopedic Association, vol. ii. Bradford and 
Lovett, New York Medical Journal, August 4, 1894. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 343 

few supporters even among those who use the traction brace 
exclusively. On the contrary, the motion that cannot be prevented 
is excused because of the practical efficiency of the brace and 
because it is believed that no more effective protection can be 
attained by any other method of ambulatory treatment. 

■ In all acute cases a period of rest in bed with traction to the 
point of actual distraction is advised. When ambulation is 
resumed the braced limb is made pendent by means of the high 
shoe and crutches, so that uninterrupted traction may still be 
exerted, and the brace is only used as a supporting appliance 
when the symptoms indicate that the disease is quiescent. 

As has been stated, treatment by the long traction brace, by 
means of which motion without friction was at one time claimed 
to be possible, and in which traction is the distinctive feature, is 
sometimes called "The American Treatment of Hip Disease." 
In this sense the direct splinting of the joint without traction, by 
means of the Thomas brace, might be called in distinction "The 
English Treatment." 

The Thomas Treatment of Hip Disease. — H. O. Thomas, 1 of 
Liverpool, writing at a time when in America it was generally 
believed that motion was essential to the well-being of a diseased 
joint, and when fixation was supposed to predispose to, or to 
actually induce, anchylosis, states "that continuity of exten- 
sion per se is not a remedy in hip-joint disease; in its appli- 
cation it involves unavoidably a fractional degree of fixation 
which is sufficient to mask the evil of this ridiculous mal- 
practice." 

The conclusions on which his treatment is founded are these: 
"The main obstacle to the cure of an inflamed joint is the friction 
and pressure of its surfaces; consequently the attainment of rest, 
that is of immobility of the articulation, ought to be the principle 
which should guide the treatment. Pressure and concussion are 
less to be feared than friction. Effectual rest can only be ob- 
tained by mechanical treatment, and for this purpose the appli- 
ances which I here recommend are effectual. The more an 
inflamed joint is moved the stiffer does it become; while the more 
effectually it is fixed, the sooner and the more completely is its 
capability of movement restored. To ensure permanency of 
cure the control should be maintained for a period beyond the 
time when resolution has taken place. This prolonged arrest of 

1 Diseases of the Hip, Knee, and Ankle-Joints Treated by a New and Effective Method, 
1875, p. 10. 



344 ORTHOPEDIC SURGERY 

a joint's movements, for even an unnecessarily long period, I 
have never found to do harm." 

The splint used by Mr. Thomas to carry out these principles 
effectively is described by him substantially as follows: 

A flat piece of malleable iron, three-quarters of an inch wide 
and three-sixteenths of an inch thick for children, and one inch 
by one-quarter inch for adults, long enough to extend from the 
lower angle of the scapula to the middle of the calf, forms the 




The Thomas hip splint, covered and fitted with shoulder straps. 
(Ridlon and Jones.) 

upright. This is fitted to the body of the patient, 
passing from the lower angle of the scapula, in 
a perpendicular line, downward, over the lumbar 
region, across the pelvis, slightly external, but 
1 1 ^j close to the posterior spinous process of the ilium 

_ ,. . , x . and the prominence of the buttock, along the 

The splint m its sun- r ' o 

piest form, not yet pad- course of the sciatic nerve to a point slightly ex- 
ion.) 01 C ° Vere " ternal to the calf of the leg. It must be care- 
fully modelled to this track. The lumbar por- 
tion of the upright must be invariably almost a plane surface, but 
it must be twisted slightly on its long axis at the junction of the 
upper and middle third, so that the anterior surface of the lower 
part may look slightly outward to correspond to the contour of 
the buttock and thigh. A second and double bend is made in 
the upright at the point where it passes the buttock, so that the 
thigh part lies on a slightly higher plane than the body part, but 
parallel with it. The upright is then provided with chest, thigh, 
and leg bands (Fig. 221). 

The chest band is of hoop iron, one and a half inches in width 
by one-eighth of an inch in thickness. This is bent into an oval 
to correspond with the shape of the chest, being four inches less 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



345 



than the circumference at this point if the patient is an adult, 
and of a corresponding size for a child. It is riveted to the upper 
extremity of the brace, so that one-third of its length shall be on 
the side corresponding to the diseased joint and two-thirds on the 
other. The thigh band and leg band are of similar material, 
three-quarters by one-eighth of an inch in size. The thigh band, 
in length equal to two-thirds of the circumference of the thigh, 
is fastened to the upright at a point one to two inches below the 
buttock, and the calf band, equal in length to half the circum- 
ference of the leg at the calf, is riveted to the lower extremity of 
the brace. Both the thigh and leg bands are attached to the 

Fig. 223 




Method of changing the line of pressure on the skin from the Thomas hip splint by 
drawing the tissues to one side. (Ridlon and Jones.) 



brace at points slightly to the inner side of the centre, so that the 
outer arm of each band is somewhat longer than the inner. The 
brace is padded with thin boiler felt and is covered smoothly with 
basil leather. In fitting the brace to the patient the long part of 
the chest band should be made to hug the body closely, while 
the short arm should be somewhat away from it. The anterior 
surface of the thigh part of the upright should have a perceptible 
outward twist and should be somewhat on the inner side of the 
popliteal space. Thus the instrument is prevented from rota- 
ting outward and becoming a side splint. The chest band is 



346 ORTHOPEDIC SURGERY 

closed with a strap and buckle; it is suspended by shoulder straps, 
and the leg between the two bands is attached to the brace by 
means of a flannel bandage. Ridlon states that in practice this 
bandage is usually replaced by a strip of basil leather passed 
across the front of the limb close down to the upper border of 
the patella, thence backward and downward to the stem of the 
splint and pinned to the covering, so that the resistance to the 
downward working of the brace is borne by the quadriceps femoris 
muscle. The ordinary shoulder straps may be replaced by a 
single bandage looped about the upper part of the stem (Fig. 223). 
This bandage is twisted for a length of about six inches, then 
separated, the ends being carried over the shoulders, are passed 
through holes in the corresponding ends of the chest band, where 
they are knotted, and finally the two ends are tied to one another, 
completing the circumference of the chest band. 

This brace is fitted by the surgeon directly to the patient's 
body as he stands erect. If the limb is already flexed the foot 
is raised by blocks until the lumbar lordosis is straightened; the 
brace is then bent to fit the angle of deformity and is applied in 
the usual manner. 

The brace is made of iron because it is less elastic than steel, 
and because it can be more easily twisted by' wrenches. It must 
be heavy and strong in order to splint the part effectively, and 
it can only be an effective splint when it is fixed in its proper 
position and exercises direct pressure upon the hip-joint. In 
cases in which the brace has been properly adjusted a deep 
furrow should appear in the buttock directly over the neck of the 
femur. Once fitted to the patient it is changed only at infrequent 
intervals and always by the surgeon, who is particularly careful 
not to move the limb during the active stage of the disease. 

The double Thomas hip splint is made by joining two single 
splints. These are riveted to the chest band above and are con- 
nected at the lower ends by a crossbar unless the brace is to be 
used in the reduction of deformity. Care must be taken that 
the uprights pass to the outer side and not directly over the poste- 
rior superior spines of the ilium. 

The Reduction of Deformity by the Thomas Method. — Preferably 
in the treatment of children the double brace is applied, the sound 
limb being fixed in the extended position while the flexed limb is 
supported by the other arm of the brace, bent to the angle of 
deformity. The patient is confined to the bed and, as the mus- 
cular spasm relaxes under the influence of enforced rest, the brace 



TUBERCULOUS DISEASE OF THE HIP-JOINT 347 

is straightened slightly by wrenches from time to time, at a point 
opposite the joint, to conform to the improved position until 
symmetry is restored. In resistant cases this gradual relaxation is 
hastened by straightening the brace somewhat at intervals, to 
which the attached limb must conform — a gradual forcible reduc- 
tion of deformity. According to Ridlon and Jones, the flexed 
limb is often forced to conform to the straight brace by a tem- 
porary exaggeration of the lumbar lordo is which lessens as the 
spasm subsides under treatment. 




Thomas splint applied with patten and crutches. 

The treatment is divided by Mr. Thomas into stages: 

1. A preliminary stage of rest in bed for the reduction of 
deformity and to allow for subsidence of acute symptoms. 

2. The patient is then allowed to go about on crutches wearing 
an iron patten at least four inches in height under the sound 
foot (Fig. 224). 

3. When all symptoms of disease have subsided and when atrophy 
of the muscles is marked the brace may be removed at night. 



348 



ORTHOPEDIC SURGERY 



4. The brace is finally discarded, but the patten and crutches 
are still used in walking. 

According to Ridlon 1 the records of Mr. Thomas show the 
average time of confinement to the bed to be twenty-two weeks, 
and the average duration of treatment twenty-one months. 

It is stated by Ridlon 2 that in actual practice these principles 
were not carried out, for nearly all the children treated under 
Thomas' direction at the time his observations were made were 
walking about without the high patten and crutches, even before 
the deformity had been overcome and while muscular spasm and 
pain persisted. 

This was, however, probably an exigency of practice among 
the poor, and at all events it is in line with Thomas' contention 
that pressure and concussions are less harmful than friction. 




A form of Thomas brace employed in the treatment of infants. The pelvic band assures 
better fixation. The screws at the lower extremity are arranged to permit the addition of 
a foot-piece for traction. 

Modifications of the Thomas Brace. — Although not so stated in 
his book, Thomas used at times a short brace extending only to 
the lower part of the thigh, thus permitting motion at the knee. 
This was apparently designed as a convalescent splint, although 
its use was not restricted to that class of cases. In certain cases 
a strip of iron, "the nurse," was screwed to the lower extremity 
of the long brace, prolonging it beyond the foot in order to pre- 
vent the patient from bearing weight upon the limb. 

The Thomas brace, so effective in preventing and overcoming 
flexion deformity, does not prevent lateral distortion. In fact, 
in twenty-four of the fifty-eight patients examined by Ridlon, 3 
adduction was present; a larger proportion, it would appear, 
than would be found in a like number of cases under treatment 



1 Transactions American Orthopedic Association, vol. i. p. 17. 

2 A report of Sixty-two Cases of Hip Disease Observed in the Practice of Hugh Owen 
Thomas, New York Medical Journal, October 4, 1890. 

3 Loc. cit. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 349 

with the traction brace. This tendency to lateral distortion may 
be guarded against by placing a half band of material similar to 
the chest band about the side of the pelvis; on the same side 
for adduction, on the opposite side for abduction of the limb. 

The Thomas brace has a great advantage over other appliances 
in its simplicity. It can be made by a blacksmith, but it must 
be fitted by the surgeon. This fitting requires great care. In 
the words of Mr. Thomas: "The fitting although sometimes 
successful in one visit, may at other times occupy many days. 
The surgeon should mould, by reducing or increasing the various 
curves, until the instrument ceases to tend to rotate, and at none 
of its angles irritates the patient." He concludes, in a general 
answer to the criticisms that have always been made on the diffi- 
culty of adjustment of the appliance, as follows: "What I can 
invariably do must be possible to others." 

Treatment by the Plaster Bandage. — A third routine method of 
treatment is that by means of the plaster bandage without crutches 
or high shoe. This is simple splinting with whatever protection 
from concussion the support may assure. 

This treatment might be called the German method if the 
traction hip splint and the Thomas brace are to be designated as 
American and English. 

As used in the surgical clinic at Berlin, the plaster bandage is 
applied from the line of the nipples to include the foot, the limb 
being fixed in an attitude of slight flexion, abduction, and out- 
ward rotation. As a rule, the first bandage is applied under 
anaesthesia for the purpose of relaxing the muscular contraction 
and facilitating the application. If nutritive shortening of the 
muscles is present, sufficient force is employed to overcome the 
deformity. The spica is renewed at intervals of from two to four 
months. When the disease is cured and after the bandage is 
finally removed traction at night is employed for a time by means 
of a weight attached to the foot to prevent the tendency to dis- 
tortion. In ambulatory treatment this method has little to recom- 
mend it except expediency, but as a temporary support to be used 
before the application of a suitable brace the plaster spica is most 
useful. 

When properly applied it is an admirable support, often far more 
comfortable to the patient than any brace, and it is at times an 
indispensable form of dressing. It has the same defects as the 
plaster jacket, and it may receive the same defence that its most 
severe critics have had the least experience in its use. 



350 ORTHOPEDIC SURGERY 

Application of the Long Plaster Spica Bandage. — A plaster 
bandage to assure support should fit perfectly, consequently it 
should be applied as closely as is possible. A close-fitting covering 
of shirting, such as is used in the application of the plaster jacket, 
is drawn on and is covered with one or more layers of cotton 




The long plaster spica bandage. The dotted line indicates the position of the 
steel support. 

flannel bandage, those parts that are likely to be subjected to pres- 
sure — the toes, the heel, the malleoli, the condyles of the femur, the 
sides of the pelvis, the anterior superior spines, and the thorax — 
being suitably protected by cotton wadding or other material. The 
plaster bandage should cover the lower half of the thorax, and it 



TUBERCULOUS DISEASE OF THE HIP- JOINT 351 

should extend to the ends of the toes. It should be applied under 
slight traction, very carefully around the adductor region and the 
buttock, which should be entirely covered and supported. At 
this point, in the line in which the bar of the Thomas hip splint 
runs, a piece of splint wood or a strip of malleable steel, long 
enough to reach from the middle of the trunk to the lower third 
of the thigh, should be incorporated in the plaster (Fig. 224). 
A similar piece is sometimes placed in front of the hip and another 
beneath the knee, the points at which the bandage is likely to 
break. The proper anteroposterior support of the buttock, con- 
sequently of the hip-joint, which is of the first importance, is 
almost invariably neglected in the ordinary application. The 
bandage may be applied in the upright posture by means of 
the swing, as used in the application of the plaster jacket, the 



Box with adjustable sacral support used for the application of plaster spica bandage. 

weight being supported in part by the sound leg while the other 
is pendent. Usually it is applied with the patient in the reclining 
posture, the body being supported by a shoulder rest, and the 
pelvis by a sacral support. The arms are then drawn above the 
head to increase the capacity of the thorax, while the limbs are 
supported by an assistant (Figs. 227 and 230). 

In the more recent cases, deformity may be practically reduced 
at the second application of the bandage, because of the relaxation 
of the spasm assured by the rest and fixation; thus it is particu- 
larly useful in the treatment of young children in the outdoor 
practice, for whom hospital care would otherwise be required. 

The Short or Lorenz Spica Bandage. — The short spica 
bandage is used as routine treatment of hip disease in Lorenz's 
clinic in Vienna unless direct weight bearing causes pain. It is 
applied in the manner described under the treatment of congenital 



352 ORTHOPEDIC SURGERY 

dislocation of the hip, the aim being to fix the affected limb in 
an attitude of slight flexion and abduction, the primary attitude 
of hip disease. A close-fitting covering of shirting is drawn over 
the limb and pelvis, and a wide bandage is then introduced be- 




The Lorenz spica, showing the adjustment to the pelvis. In this case it is extended below 
the knee, but in many instances motion at the knee-joint is permitted. 

tween the skin and shirting to serve as a "scratcher." The bony 
prominences are suitably protected by cotton or sheet wadding, and 
the bandages are then applied, being drawn closely and carefully 
moulded about the pelvis and thigh, so that movement in the joint 
may be controlled. The upper and lower extremities of the bandage 



TUBERCULOUS DISEASE OF THE HIP- JOINT 



353 



are cut away as illustrated (Fig. 228), and the shirting is then drawn 
over the margins of the plaster and sewed. This makes a smooth 
covering and holds the padding in position. If the bandage is ex- 
tended below the knee it is more efficient. As an adjunct to 
mechanical support and during the stage of recovery, or even in 
the treatment of cases of a mild type, the bandage is very satis- 
factory, but as a routine treatment it is not a sufficient protection. 
It should be stated that in the treatment of the more acute cases 
by Lorenz the weight of the body is removed by a prolongation 
or stirrup of sheet steel which projects beyond the foot, the two 
extremities being incorporated in either side of the plaster bandage 
in the neighborhood of the knee (Fig. 229). In 
the better class of cases a leather support pro- 
vided with a steel foot-plate extending slightly 
below the foot and a joint at the knee is used. 
The short spica bandage in combination with the 
traction hip brace (Fig. 237) answers the same 
purpose and is more efficient if somewhat more 
cumbersome. 

Immediate Reduction of Deformity. — In the more 
resistant cases an anaesthetic may be administered. 
If the deformity is due simply to muscular spasm 
the limb may be placed in the proper position 
without force; but if, as is often the case when 
the distortion is of long standing, it is caused in 
part by shortening of the muscles and fasciae, a 
certain amount of force may be required. 

The pelvis should be fixed and the force 
should be applied as far as possible by direct trac- 
tion rather than by leverage. Subcutaneous divi- 
'sion of the contracted tissues about the anterior 
superior spine and in the adductor region may be 
required. In very resistant cases the reduction 
of deformity by this method should be divided into several oper- 
ations. Lorenz reduces the adduction deformity by means of a 
machine that exercises direct traction on the adducted limb while 
the sound limb is pushed upward, so that practically no leverage 
is exerted on the joint. 1 

In cases in which the deformity is accompanied by abscess, or 
when the joint is surrounded by infiltrated tissues and by sinuses, 
this treatment should not be employed. In fact, in certain cases 

1 Lorenz, Sammlung klin. Vor., 206, Leipzig, March, 1898. 

23 




The Lorenz stilt, 
sometimes used in 
the treatment of the 
more painful cases. 
This is incorporated 
in the plaster band- 
age above the knee 
and it extends below 
the foot. 



354 



OB THOPEDIC S UB GEB Y 



of this class, especially when subluxation is present, it is often 
advisable to disregard the deformity that cannot be reduced by 
traction until the disease is cured, when it may be overcome by 
osteotomy of the femur. 

The immediate reduction of deformity, properly performed, is 
free from danger; and it has become almost the routine of prac- 
tice in the indoor department of the Hospital for Ruptured and 
Crippled. The great advantage of placing the limb in the proper 
position and fixing it for weeks or months, combined with trac- 




A pelvic support in use. The patient presents fixed flexion to 135 degrees, and fixed 
adduction of 35 degrees. 



tion, if this seems advisable, instead of employing this time for the 
gradual reduction of the deformity, is, of course, self-evident. 
Three methods of reduction of deformity have been described: 

1. By means of the traction brace. 

2. By means of the Thomas brace. 

3. By means of the plaster bandage, with or without anaes- 
thesia. 

A fourth method is that by means of the weight and pulley. 
This is in common use because it requires no special apparatus. 



TUBERCULOUS DISEASE OF THE HIP- JOINT 



355 



Reduction of Deformity by the Weight and Pulley. — 
The traction plasters are applied to the limb in the manner 
already described, and the patient is placed on his back on a 
narrow, firm mattress. The limb is raised until the lumbar vertebrae 
rest upon the bed and it is then moved to one or the other side, 
if lateral distortion is present, until the level of the pelvis is 
restored. In this position the limb is supported on a pillow, or 



I 




Weight extension acting as leverage in hip disease. P, pulley; W, weight; F, fulcrum. 
Marsh's diagrams, illustrating the advantage of traction in the line of deformity, in order 
to avoid leverage. (Howard Marsh., 

better, on the adjustable triangle used with the traction hip splint 
(Fig. 219). A pulley is then attached to the foot of the bed in 
a prolongation of the line of the flexed limb. The wheel may 
be screwed to the top of a narrow board, which may be raised 
or lowered on the foot of the bed as required. To the buckles on 
the plaster traction straps, a stirrup carrying the cord is attached 
This stirrup is simply a spreader of narrow thin wood, slightly 
wider than the foot, provided at either end with straps or tapes, 




Posture of the limb in hip disease in which extension should be applied in order to 
avoid leverage. P, pulley; W, weight; F, fulcrum. 

its purpose being to prevent direct pressure on the malleoli (Fig. 
234). By means of a weight suspended at the foot of the bed 
traction is made upon the limb to the extent that the comfort 
of the patient will permit. As in Buck's system of traction, 
the foot of the bed is raised to increase the friction of the body 
and thus to counteract the traction force, but in the treatment 
of children this is inefficient and countertraction must be provided. 
A simple method is to attach two perineal bands, as described 
in connection with the traction brace, to strong tapes that pass 



356 



OR THOPEDIC >S UR GER Y 



above and below the patient's body, to be fixed to the head of 
the bed at a suitable distance from one another; thus the pelvis 
is supported by prolonged perineal bands. 

In order to assure efficient and constant traction the patient must 
be prevented from sitting up. For this purpose a swathe about the 
body or shoulder straps may be applied and attached to the bed. 

A convenient appliance is that of Marsh: "This consists of 
a piece of webbing, passing across the front of the chest and 
ending in two loops, through which the two arms are passed, 
and through which is threaded another piece of stout webbing 
which runs transversely across the surface of the bed under the 
child's shoulders, and is fastened at its two ends to the sides of 
the bedstead. When this is in action the patient's shoulders 
are kept flat on the bed, so that he can neither sit up nor turn 




Extension in hip disease. Marsh's method of fixing the patient in bed with shoulder 
straps and a long T-splint on the sound side. (Howard Marsh.) 

on his side. This chest band does not cause the slightest dis- 
comfort. It is not, of course, fixed tightly, and when the child 
finds that he cannot sit up he makes no further attempt to do 
so; and as he lies flat the band is loose." 

It is often of advantage, particularly if the disease is active, 
to use some form of apparatus to fix the patient more thoroughly. 
Marsh uses a long lateral splint of thin board reaching from the 
axilla to a crossbar below the sole of the foot. To this the pa- 
tient's body and sound limb are bandaged (Fig. 233). 

For the same purpose a plaster spica bandage or a Thomas 
splint may be applied on the sound side, but a more convenient 
appliance is the frame of gas-pipe covered with canvas that has 
been described in the chapter on Pott's disease. Upon this frame 
the patient can be fixed, the limb being elevated by a support 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



357 



attached to the frame or independent of it (Figs. 234 and 235). 
It is perhaps needless to suggest that the bedclothes must be held 
from the elevated limb; in fact, that the patient must for a time 




Traction by means of weight and pulley. (R. T. Taylor.) 
Fig. 235 




Method of fixing the patient to the Bradford frame for traction in hip disease. 
(R. T. Taylor.) 

be enclosed in a tent of bedclothes if the deformity is extreme. 
At first the traction weight must not be great, but as the peri- 
neum becomes accustomed to pressure as much weight as can be 



358 ORTHOPEDIC SURGERY 

tolerated is used, from ten to twenty pounds being the average. 
This may be reduced at night and increased during the day. 
Great care must be taken to prevent painful pressure on the 
perineum by careful adjustment and frequent inspection of the 
perineal bands. 

If, the frame is used it may be provided with a windlass at 
the bottom for traction and with an arched band of metal across 
the pelvis for the attachment of the perineal bands, which behind 
are fastened to the side bars at a higher level. Thus the frame 
may be made an independent recumbent splint on which the 
patient may be moved about. If, however, one desires to exert 
traction to the point of distraction, the weight and pulley arrange- 



Lateral and longitudinal traction in hip disease. (Page.) 

ment is more satisfactory; in this case the limb should be placed 
in an attitude of slight flexion and abduction, so that the femur 
may be drawn more directly from the acetabulum. 

Lateral Traction. — Thus far longitudinal traction has been con- 
sidered, but lateral traction or traction in the line of the neck of 
the femur deserves some consideration. 

Mr. Thomas, who condemned all forms of traction as deceptive 
and irrational, and especially longitudinal traction, speaks thus 
of lateral traction: "For surely if relief from pressure be re- 
quired, the only direction in which this is possible is clearly in 
the axis of the neck of the femur. Any method of extension in 
the axis of the body merely transfers the pressure from the upper 
part of the acetabulum to the lower quarter." 1 This contention 

1 Loo. cit., p. 10. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 359 

is purely theoretical, as there is no evidence to show that injurious 
pressure is ever exerted upon this part of the acetabulum. On 
the contrary, the specimens from subjects who have been treated 
by longitudinal traction in recumbency and by means of the trac- 
tion hip splint almost invariably show the effect of pressure upon 
the upper part of the head of the femur and upon the upper ad- 
joining margin of the acetabulum. Moreover, the neck of the 
femur is in childhood so short and is set upon the shaft at so 
great an angle that longitudinal traction, if the limb is slightly 
abducted, is, practically speaking, in the line of the neck; so that 
even from the theoretical standpoint the question of injurious 
pressure could only arise in the treatment of adults. The advan- 
tage of lateral traction in the treatment of hip disease was urged 
by Phelps 1 as early as 1889, and it has been applied as a routine 
practice in ambulatory treatment by Blanchard, 2 of Chicago, 
since 1872. 

The effect of lateral traction in recumbency has been carefully 
investigated by C. G. Page. 3 His conclusions are that lateral 
traction alone is of no benefit, but if applied, together with longi- 
tudinal traction, it gives great relief in certain acute cases. The 
longitudinal traction should be twice as great as the lateral, ten 
and five pounds being the average weights employed in his ex- 
periments. The method is shown in the illustration (Fig. 219). 



The Relative Efficiency of Traction and Splinting 
("Fixation"). 

In considering the vexed question of the relative merits of 
splinting and traction in preventing muscular spasm and the con- 
sequent intra-articular pressure which cause pain and increase 
the destructive effects of the disease, these facts must be borne 
in mind. 

The more acute the disease the less ability of the joint to 
carry out its proper function, which is motion. The greater the 
motion under these circumstances the more intense the muscu- 
lar spasm, of which the object is the prevention of motion. If it 
were possible, therefore, to fix the joint absolutely there should be 
no muscular spasm, although the tension of acute disease within 
the bone, or of its products within the joint, might cause pain. 

1 New York Medical Record, May 4, 1889. 

2 Transactions American Orthopedic Association, vol. vii. 

3 C. G. Page, Boston Medical and Surgical Journal, September 13, 1894. 



360 OB THOPEDIC S UB GEB Y 

When the patient is fixed in the recumbent posture it is possible 
to apply a sufficient traction upon the muscles to prevent the spas- 
modic contraction that causes injurious pressure, and although 
no amount of traction will absolutely prevent motion, yet with 
the support that the bed provides, practically speaking, complete 
rest may be assured. Only in the exceptional cases in which 
tension upon congested tissues about an acutely inflamed joint 
is intolerable is this method of treatment inefficient. 

The same statement is true of a properly applied spica bandage 
or Thomas brace, when the patient is recumbent, that it assures 
practical rest; thus it prevents muscular contraction, relieves the 
symptoms and promotes repair, although it cannot be claimed 
that the surfaces of the opposing bones are actually separated 
from one another. 

But what is true when the patient is recumbent is not true in 
ambulatory treatment. The traction exerted by the hip splint, 
even when the limb is pendent, is far less effective than in recum- 
bency, and when it is used as a walking appliance, for which it 
was designed and for which it is practically always employed, 
the traction is intermittent and of doubtful efficiency. The same 
loss in efficiency, although in far less degree, occurs in all forms 
of fixative apparatus when used in ambulation; but it may be 
stated without reserve that splinting is of far more importance 
in actual practice than is traction. 

The Removal of Direct Pressure. "Stilting." — Granting that 
the traction brace as a walking appliance is relatively inefficient 
in preventing motion, and that motion without friction, provided 
the joint surfaces are actually involved, is impossible, still the 
traction brace is, or may be, at all times an effective stilt in that 
it protects the joint from concussion and pressure by removing 
the foot from contact with the ground. 

It is true that the removal of direct pressure may be assured 
by the use of axillary crutches, but in Thomas' practice they 
were used in but few cases. 1 In fact, it is only by constant super- 
vision that the use of crutches can be enforced upon children who 
no longer suffer pain; and as it is practically impossible to pre- 
vent the patient from bearing weight upon the limb, stilting by 
this means is relatively inefficient. 

That direct pressure is one of the causes of upward displace- 
ment of the fpmur may be inferred from the statistics of Sasse 

1 Ridlon, loc. cit. 



TUBERCULOUS DISEASE OF THE HIP- JOINT 361 

and Brans/ from the surgical clinics of Berlin and Tubingen, 
where the routine of treatment is the plaster bandage without the 
high shoe or crutches. In two-thirds of Sasse's and in four-fifths 
of Brans' cases there was upward displacement of the trochanter. 
This is certainly a larger proportion than would be found in a 
corresponding class of patients treated by efficient stilting, although 
statistics on this point from American sources are lacking. 

The Practical Combination of Traction. Splinting and Stilting. — 
Thus far the methods of treatment by splinting and traction 
have been presented as if they were opposed to one another in 
principle as indeed they are in practice. For in this country the 
prevailing treatment is still the traction hip splint; in England 
the Thomas hip brace, and on the Continent the plaster support. 

It should be recognized, however, that the principle involved 
in each method is the same, and that the actual merit of each 
must be decided by practical experience rather than by argument. 
The true test of the relative value of a routine of treatment is its 
efficacy in hospital practice, where its weak points cannot be sup- 
plemented by the careful supervision that may make almost any 
method effective that carries out in some degree the proper prin- 
ciple. This test is all the more necessary because the great major- 
ity of cases of this character are to be found among the poor. 

From this point of view the writer's experience may be of 
interest. His early training was entirely in the traction method, 
but the observation of a large number of cases in which this treat- 
ment was used led to the following conclusions: 

In one sense the treatment was successful, in that it in great 
degree relieved the symptoms throughout the course of the dis- 
ease and enabled the patients to go about in the open air, to 
attend to school, and even to join in the games of their fellows. 
It was evident, however, from an inspection of the patients as 
they returned for treatment, that the relief of symptoms was due 
to the protection ensured by the stilting or crutch-like action of 
the brace and not by traction, which was usually simply traction 
in name, not in fact. But if the brace relieved the symptoms, it 
did not, in many instances, prevent deformity; and as the preven- 
tion of deformity is an object only secondary in importance to the 
relief of pain, the treatment was in so far unsatisfactory. This 
deformity was usually flexion, occasionally combined with adduc- 
tion, a deformity often increasing slowly without pain, or other 

1 Sasse, Arbeit aus der klin. Chir., Berlin, 1896. Brans, Archiv f. klin. Chir., Bd 
xlviii., H. 1. 



362 ORTHOPEDIC SURGERY 

evidence of greater activity of disease. If the deformity were 
reduced by traction in recumbency, it reappeared when ambu- 
latory treatment, by the brace, was resumed. This flexion seemed 
to be in many instances simply an adaptation to the prevailing 
postures. When, for example, the patient assumed the sitting 
position, the limb was flexed in spite of the brace, and as much 
of the time was passed in this attitude, its influence on the pro- 
duction of deformity seemed to be obvious. 

The most accurate statistics of final results in cases treated 
by this apparatus illustrate also its ineffectiveness in preventing 
deformity. Thus in a total of thirty-five cases treated at the N. Y. 
Orthopedic Dispensary 1 practical anchylosis was present in 74° 
and in 60° the limb was distorted to a greater or less degree. 




The short spica bandage reaching to the knee in combination with the brace. One 
perineal band has been removed in order to show how the joint is supported by the band- 
age. The short spica of the Lorenz model may be used also for this purpose. 

It was also apparent that the brace was not effective in relieving 
pain during the more acute exacerbations, even during recum- 
bency with such traction as could be applied by the parents ; nor 
when the children were brought in arms to the clinic. 

Under these conditions it was found that acute symptoms 
might be relieved, or greatly modified, almost at once, by the 
application of a close-fitting short spica bandage extending from 
the middle of the thorax to the knee. Over this the brace was 
applied as before, making an apparatus which then combined 
splinting, traction, and stilting (Fig. 237). This treatment was 
repeated in many instances, always with the same result. As 
the application of the plaster bandage was a somewhat tedious 

1 Shaffer and Lovett, New York Medical Journal, March 2, 1878. 



TUBERCULOUS DISEASE OF THE HIP- JOINT 



363 



Fig. 238 



proceeding, it was often exchanged for a short Thomas splint 
worn beneath the pelvic band of the traction brace in the same 
manner. The fixation appliance not only relieved pain in the 
acute cases, but it also prevented the deformity, which was not 
checked by the traction brace alone. 

This combination of the short Thomas brace and the traction 
hip splint was effective as a means of relieving pain and preventing 
deformity. It had, however, the 
disadvantage of requiring care- 
ful adjustment, and it obliged 
the patient to wear shoulder 
straps; in other words, much 
care must be exercised to en- 
sure the comfortable adjust- 
ment of both appliances. Thus 
the next step was the combina- 
tion of the two, even though the 
action was somewhat less effec- 
tive. To the pelvic band of the 
traction brace a lateral thoracic 
bar was attached, reaching up- 
ward in the axillary line to a 
point opposite the middle of the 
scapula, where it was joined to 
a metal band that encircled the 
chest, like that of the Phelps 
brace. When this was securely 
fastened about the chest, the 
body and the limb were held in 
line by a long lateral brace; the 
pelvis was supported by the pel- 
vic band and the joint received 
the additional protection that 
was assured by traction and 
stilting (Figs. 238 and 239). 

This brace is now in general 
use at the Hospital for Ruptured and Crippled. Its efficiency may 
be still further increased by replacing the perineal bands with a 
metallic ring. This ring, which fits the upper extremity of thigh 
closely, is attached to the upright at an inclination corresponding 
to the line of the groin (Fig. 240). (The Thomas ring is described 
fully in connection with his knee splint.) It is a better support 




The long, inexpensive brace, with solid up- 
right, showing the perineal bands and the ad- 
hesive plaster, as used in hospital practice. 



364 



OB THOPEDIC S UB GEB Y 



because it prevents anteroposterior motion within the pelvic band, 
which the perineal straps allow. The ring may be used as the 
only support or it may be combined with a perineal band on the 
opposite side. This is of advantage if there is a tendency toward 
adduction. 

The apparatus is most satisfactory when the hollow upright of 
the Taylor brace is used. This is light and strong, and is pro- 
vided with an arrangement for effective traction, but in hospital 
practice the upright is made of solid metal, and the traction is 
made by simple straps. The metallic ring, besides providing 
better fixation, is a firm support that cannot be removed by the 
patient. It is, of course, more difficult of adjustment, and it is 
not suited to the treatment of young children because of the diffi- 
culty in keeping it clean and dry. 




The long hip splint applied. 

The Thomas ring was first applied to a hip splint by Phelps 
(Fig. 242). He urged the advantages of fixation and traction, and 
his brace, of which that last described is simply a slight modi- 
fication, is provided with an arrangement for lateral traction. 
Practically speaking, this is a tape by which the lower third of 
the thigh is held in apposition to the upright. It hardly seems 
possible that appreciable lateral traction can be exerted on the 
joint by this means if the metallic ring is properly fitted to 
the thigh. The simple straps do not afford as effective traction 
as the rack and pinion, nor is the brace, as usually constructed, 
sufficiently strong to bear the weight of the body without bend- 
ing. It should be stated, however, that this form of brace is 
intended to be used with crutches rather than as a walking appli- 
ance. 

Certain objections to this attempt to combine effective splinting 
with traction and stilting have been urged by those who believe 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



365 



in the efficiency of the ordinary traction brace. For example, it is 
said that the splinting is ineffective because the movements of the 
trunk are transmitted to the joint, while this is not true of braces 
that do not extend above the pelvis. 





The long brace, with Thomas ring and ex- 
tension upright, similar to Phelps' brace. 



Rear view of brace. 



As a matter of experience, it will be found that motion of the 
upper part of the trunk is absorbed, as it were, in the flexible 
lumbar region of the spine before it reaches the joint. If, however, 
such motion or any motion causes discomfort or aggravates the 



366 



ORTHOPEDIC SURGERY 



symptoms, the patient should be confined in the recumbent 
posture until the acute phase of the disease has passed. It is said 
that the brace is cumbersome, that the patient cannot sit with 
comfort, and that it prevents normal activity. A long brace cer- 
tainly weighs more than a short one, and if a brace prevents 
flexion of the hip and spine it is evident that the patient cannot 
sit with comfort in an ordinary chair. 




The Phelps hip splint 




A chair to be used with the long hip splint. The 
patient sits upon the sound side, while the splinted 
half of the body remains in the extended position, 
the brace resting on the floor. 



The patients themselves, however, make little complaint of 
the brace, even when it has been substituted for an ordinary 
traction splint; while the greater restraint of activity is a favor- 
able element of treatment, since children who do not suffer pain 
are much more likely to be too active than to be harmfully re- 
strained by any form of appliance. These objections are trivial 
if one is convinced that the dangerous and deforming disease 
that is under treatment may be more easily controlled and that 
the final result is likely to be better and to be more rapidly attained 
by this means than by another. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



367 



It would be of advantage, of course, if a brace could be so 
adjusted to the pelvis and to the femur as to fix the joint without 
interfering with the movements of the spine. Such fixation can 
be attained by a close-fitting plaster bandage of the Lorenz 
model (Fig. 228) used in conjunction with traction plasters. 



Fig. 245 




The Lorenz spica combined with the traction 
hip brace. The perineal strap prevents dis- 
placement of the plaster appliance. 



Lateral view. The shape of the pelvic band is like that 
illustrated in Fig. 248. 



To these a short traction hip brace of the Taylor model, as shown 
in Figs. 244 and 245 is adjusted. 

It will be noted in the illustrations that the limb is fixed in a 
moderate degree of abduction. This attitude is indicated because 
the tendency of the disease is toward adduction, the attitude in 



368 ORTHOPEDIC SURGERY 

which the destructive changes in the joint that lead to upward 
displacement of the trochanter take place. Abduction lessens 
the pressure also of the articulating surfaces on one another, and 
whatever the appliance used it should be adjusted to favor this 
attitude. 

It may be noted that there is a very general tendency to shorten 
the period of stilting and to permit weight bearing when it no 
longer causes discomfort. This is based on the fact that complete 
cessation of function for long periods leads to extreme atrophy 
of the limb, to relaxation of the joints, and to loss of growth. 
Even if early weight bearing lessens the range of motion, yet the 
function of the limb is ultimately better and the period of com- 
plete disability shorter than under the brace treatment prolonged 
through many years. 

Perhaps the most effective treatment of a case of hip disease of 
the ordinary type is immediate reduction of deformity under anaes- 
thesia. The limb to which traction plasters have been applied is 



The short plaster spica, combined with traction used after reduction of deformity. 

then fixed by means of a Lorenz spica bandage in an attitude 
of complete extension and moderate abduction (Fig. 246). A 
traction weight of about ten pounds is applied, and is con- 
tinued imtil all discomfort has ceased, usually for several 
weeks. 

A perineal crutch of the Taylor model is then applied as a walk- 
ing apparatus (Fig. 244). By this means one assures the essentials 
of protection, and the prevention of deformity without including 
the thorax in the apparatus, but to be effective the plaster spica 
must be renewed as soon as it becomes loose. When the disease 
appears to be quiescent the brace is tentatively removed to allow 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



369 



the patient to bear weight on the limb. For assuming that pres- 
sure without movement is less harmful than motion without pres- 
sure one may restore the stimulation of the weight bearing function 
and yet protect the part more effectively than by the ordinary hip 
brace. This treatment, although the most satisfacory in practice, 



Fig. 248 






The Lorenz spica illustrating the adjustment to 
the pelvis and the perineal band. 



The Taylor hip splint as used by- 
Taylor in the later years of his practice 
with but one perineal band. The illus- 
tration shows also an appliance for pre- 
venting or for correcting slight degrees 
of adduction, while the brace is in use 
as a walking appliance. The abduction 
bar is buckled about the upper extrem- 
ity of the other thigh. (H. L. Taylor, 
Medical News, March 23, 1889.) 



requires, however, more care and skill in adjustment of the appli- 
ances than the methods previously described. 

The impression that one might receive from descriptions of the 
treatment of hip disease is that most cases begin acutely, or that 
when the patients are brought for treatment the disease is in an 

24 



370 



ORTHOPEDIC SURGERY 



acute stage, or that deformity is present, so that preliminary re- 
cumbency is required. But each year the proportion of early 
cases is greater, cases in which there is no deformity and in which 
acute symptoms are absent. In such instances the hip splint 




Taylor's 



ledian abduction brace used as a bed splint to overcome adduction by 
counterpressure upon the sound side. 



or plaster spica may be applied without preliminary recumbency, 
and if the joint is fixed in the normal attitude and protected a 
relatively rapid recovery without deformity and with a fair range 
of motion may be hoped for. 



TUBERCULOUS DISEASE OF THE HIP- JO INT 371 

The Treatment of Hip Disease during, the Stage of Recovery. — It 
is much easier to assure one's self that the disease is still active 
than to decide when it is cured. For the symptoms may have 
been quiescent for months or years even, under the protective 
treatment, and yet they may recur on the slightest provocation 
when this treatment has been discontinued. 




Fig. 250. — Modified brace to be worn 
during convalescence. Same patient as in 
Fig. 241. The thoracic part has been re- 
moved and the lower end of the stem has 
been made into a caliper, passing through the 
heel of the shoe. The stem is extended by 
means of the key until the heel is lifted 
slightly from the shoe ; thus the hip is re- 
lieved from shock. 

Fig. 251. — Judson's perineal crutch. This 
support suspended from the shoulders may 
be employed as a substitute for axillary 
crutches. It is also used as a convalescent 
splint in the treatment of hip disease. 



To judge of the probable duration of the disease in a given 
case, one must consider its area, its quality, and its complica- 
tions. If, for example, the primary symptoms indicate that the 
focus of infection is of limited area and is contained within the 
bone, rapid recovery, possibly in a year, may be expected; but 



372 



ORTHOPEDIC SURGER Y 



in the ordinary type of disease in which the joint has been in- 
vaded, repair can hardly be anticipated in less than three or four 
years. Supposing that sufficient time has elapsed to permit 
of natural cure, if there have been no symptoms of active dis- 
ease for a year or more, and if 
muscular spasm is absent, one 
may test the joint by removing 
the brace at night to ascertain the 
effect of simple motion without 
weight bearing. Such freedom 
will enable the patient to move 
the knee, which having been fixed 
in the extended position for so 
long usually remains stiff for a 
time; in fact, several months may 
elapse before the full range of 
motion is regained. 





Convalescent hip splint, allowing motion at the knee. (Taylor.) 

It is well, also, to remove the thoracic part of the brace to allow 
the patient more mobility at the hip. At a later time the traction 
may be discontinued and the brace may be suspended from the 
shoulders to serve as a perineal crutch (Fig. 251); or it may be 
attached to the shoe and so adjusted as to be slightly longer than 
the limb, in order that direct concussion and pressure may be 
lessened (Fig. 250). Or a brace jointed at the knee, after the 
Taylor pattern, may be employed. 



TUBERCULOUS DISEASE OF THE SIP- JOINT 



373 



This brace is so adjusted as to be slightly longer than the limb, 
so that the heel does not touch the bottom of the shoe (Fig. 253). 
Thus the weight is in great part supported on the perineal band. 
The weight of the brace may be in part supported and incidentally 
slight traction may be exerted by adhesive plaster applied above 





Details of the Taylor convalescent hip brace. 
Fig. 254, the adhesive plaster. Fig. 255, the 
foot-plate showing the method of attachment. 



The action of the Taylor convalescent 
hip brace in removing direct pressure 
illustrated by wooden model. 



the knee (Fig. 254). The foot-plate, to which the upright is 
attached, is shown in Figs. 253 and 255. 

As the strain upon the part is increased, one watches carefully 
for the return of muscular spasm or for restriction of the range 
of motion. If the range of motion does not diminish, and if the 
deformity that may be present does not increase or does not 



374 



OB THOPEDIC S URGEBY 



appear if it were absent, the brace may be removed at intervals 
and finally discarded. 

As has been stated, the short spica after the Lorenz model is 
an admirable support during the period of recovery. It prevents 
motion at the joint, yet it permits the function of support, and 
thus a gradual rebuilding of the bony structure which has become 
atrophied during the course of the disease. By means of this 
appliance the limb may be held in the desired position of slight 
abduction, and it is particularly effective when the limb, because 
of destructive changes in the joint, is inclined toward adduction. 




Double hip disease, terminating in bony anchylosis. 



It should be stated that the long-continued fixation of the limb, 
especially if combined with traction, may induce laxity of the 
ligaments and hyperextension at the knee, unless it is properly 
supported by the posterior thigh band. In the cases in which 
the atrophy is extreme and in which this laxity is present the splint 
may be discarded in favor of the fixation bandage with advantage 
(Fig. 258). _ 

This period of supervision even in favorable cases should be 
protracted, for no patient can be considered free from the clanger 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



375 



of relapse for a long time after apparent cure. If there is firm 
bony union, as in exceptional cases, cure is assured; but if 
there is simple fibrous anchylosis, and particularly if there is 
upward displacement of the trochanter, there is a strong tendency 
toward flexion and adduction, even though the disease is cured. 
In such cases it is often necessary to employ apparatus at intervals 
to reduce the deformity or to hold the limb in proper position 
until stability is assured. When the brace has been discarded, 
the patient should be trained to walk with equal steps, placing 




Hyperextension at the knee following disease of the hip-joint and its treatment 
by the traction brace. 

the limb, as far as possible, on an equality with its fellow and 
adapting in like manner the stronger to the weaker member. 

This has an important influence in checking the tendency to 
deformity and in modifying or even concealing the limp, a point 
to which Judson has repeatedly called attention. 

Bilateral Hip Disease. 



Ninety-five cases of bilateral hip disease were treated in the 

Hospital for Ruptured and Crippled during a period of ten years 

As a rule, the second hip is affected some time after the symp- 



376 



ORTHOPEDIC SURGERY 



toms of disease of the first have been apparent, but occasionally 
both joints are involved simultaneously. In most instances the 
symptoms are rather subacute, owing, very likely, to the fact 
that the activity of the patient is so restricted. 

Treatment. — The treatment is similar in principle to that of 
the unilateral form. The patient during the greater part of the 
course of the disease must be confined in the recumbent position, 
although not necessarily in bed. The double Thomas hip splint 
is a convenient means of fixation. With this apparatus traction 
by means of the weight and pulley may be employed, or the 
brace may be so modified as to provide independent traction. If 
the disease of one hip is acute and is attended by abscess forma- 
tion, excision for the purpose of lessening the strain upon the 
patient may be advisable. 




Left hip disease, showing swelling caused by abscess, also the absence of flexion deformity 

If motion is greatly restricted in both joints locomotion unless 
crutches are used is very difficult as motion at the knees can 
supply only in small part the function of the hip-joints. In such 
instances excision of one hip in the hope of obtaining a certain 
amount of motion may be considered. 



Hip Disease Combined with Disease of Other Parts. 

The most common combination is with Pott's disease. The 
two processes may be primarily distinct, but occasionally it would 
appear that the disease of the hip is caused by the infection of 
an abscess, which, coming from the spine, remains *or a long 
time in contact with the capsule of the joint. In five of one hun- 
dred and fifty cases of disease of the hip-joint of which the final 
results were reported by Gibney, Waterman, and Reynolds 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



377 



(page 395), Pott's disease was a complication, in two instances 
preceding and in three following the disease at the hip. The 
combination of the two diseases makes the mechanical treatment 
difficult. Recumbency offers the best opportunity for the effective 
adjustment of apparatus when the disease of either part is acute. 

At a later period crutches may 
be employed, together with the FlG - 260 

necessary braces. 

Hip Disease in Infancy. 

Hip disease in infancy is far 
less common than in early child- 
hood. It presents nothing of 
special interest except that its 
effect upon the function of the 
joint and upon the development 
of the limb is usually more 
marked than in older subjects. 
Tuberculous disease of this joint 
must be differentiated from in- 
fectious epiphysitis, in which 
prompt operative treatment is 
indicated. A modified Thomas 
brace is most efficient in treat- 
ment (Fig. 225). 

Hip Disease in the Adult. 

Hip disease in the adult may 
present the typical symptoms of 
the ordinary form, but it is usu- 
ally of the more subacute type. 
Not infrequently it is a com- 
plication of tuberculosis of the 
lungs. 

The subacute form of tuber- 
culous disease is often difficult 
to distinguish from osteoarthritis, if this is confined to the hip- 
joint. Gonorrhceal arthritis and impacted fracture of the neck 
of the femur may be mentioned also in differential diagnosis. 
The mechanical treatment is not difficult, but in many instances 




Untreated hip disease. Slight flexion and 
adduction (apparent shortening). The scar 
of a former abscess is seen on the outer 
aspect of the thigh. 



378 OB THOPEDIC SURGERY 

early excision may be advisable in order to bring about a rapid 
cure of the disease. This is far more important than in child- 
hood, because few adults can afford the time required for the 
natural cure, and because in many instances the general con- 
dition of the patient may demand relief from the depressing effects 
of the local disease, especially if it be complicated by suppuration. 



Abscess in Hip Disease. 

It may be assumed that a limited collection of the fluid prod- 
ucts of the tuberculous process is present in nearly every case of 
hip disease in which the joint surfaces are actually involved. In 
many instances it remains within the joint. In a larger propor- 
tion of the cases the capsule is perforated, the fluid escapes, and, 
if the quantity is sufficient to form an appreciable tumor, it is 
classed as an abscess. Such abscesses may be detected in about 
50 per cent, of the cases that are treated under ordinary condi- 
tions. 

In 1370 final results collected from various sources the per- 
centage of abscess was as appears in the following table: 

39 cases reported by Shaffer and Lovett 1 69 . per cent. 

82 " " " Gibney 2 60.0 

390 " " " Bruns, 3 Tubingen 58.3 

568 " " " Koenig, 4 Gottingen ' . 56.5 

125 " " " Sasse, 5 Berlin . 50.0 

82 " " " Prendlsburger, 6 Vienna 51.0 

84 " in private practice, C. F. Taylor 7 25.0 

Most often the abscess first appears upon the anterior and 
upper parts of the thigh, in the space between the sartorius and 
tensor vagina? femoris muscles. In other instances it may be 
detected first on the inner side of the thigh, or it may form a 
tumor beneath the gluteal muscles, its situation being influenced 
by the point at which the capsule is ruptured. 

In rare instances the acetabulum may be perforated and a 
pelvic abscess may be formed, or the pus may find its way into 
the pelvis along the iliopsoas muscle; and occasionally a pelvic 
abscess may exist which appears to have no direct communica- 
tion with the joint. 

1 New York Medical Journal, May 21, 1887. 

2 New York Medical Record, March 2, 1878. 
8 Beit, zur klin. Chir., 1895, Bd. xxx. 

4 Die Spec. Tuberculose der Knoch u. Gelenke, Berlin, 1902. 

6 Arbeit aus der Chir. klin. der K. Univ. Berlin (Bergmann's clinic), 1896. 

6 Behand. der Gelenktuberculose und ihre Endresultate aus der klinik Albert, Wien, 1894. 

7 Boston Medical and Surgical Journal, March 6, 1879. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 379 

According to Koenig 1 the weakest point of the capsule is in 
the anterior wall, where it is covered by the iliopsoas muscle and 
by its bursa, which often communicate with the joint. A second 
weak place is in the posterior wall. 

In a total of 321 abscesses in hip disease recorded by Koenig 
the situation was as follows: 

On the inner side (inside the femoral artery) 26 

Front of the joint (between artery and anterior superior spine) . . . 126 

Region of the trochanter 63 

Posterior surface 49 

In the pelvis ■ 41 

In other situations 16 

The tuberculous abscess is a symptom and common accompani- 
ment of hip disease, which, in cases treated under proper condi- 
tions, is not of great importance; and yet, on the other hand, it 

Fig. 261 




Abscess in hip disease. The brace is provided with the Thomas ring and with 
the ratchet extension. 

is recognized as a dangerous complication. It is dangerous to 
life because of the profuse suppuration that may follow infection, 
and to function because of the adhesions and contractions that 
may result. This is evident in all statistics. It is clearly shown 
in those of Bruns. In this list the mortality in the non-sup- 
purative cases was 23 per cent., and of the suppurative 52 per 
cent. 

The Significance of Abscess. — If abscess appears early in the 
course of the disease, it usually indicates that it is of a destruc- 
tive character, and that the interior of the joint is involved; there- 
fore, perfect function is less likely to be preserved than in those 
cases in which the disease has been confined to the interior of 
the bone. 



380 ORTHOPEDIC SURGERY 

Abscess formation is often preceded by an acute exacerbation 
of symptoms, by pain, by an increase of muscular spasm and 
consequent distortion, and often by an elevation of temperature. 
These acute symptoms subside and a fluctuating swelling appears. 
It may be inferred that the pain in such a case was due to the 
tension of the abscess within the capsule, and that the relief of 
pain followed perforation and the escape of the fluid. 

In perhaps the larger proportion of cases, more especially 
those in which the joint has been protected, the formation of the 
abscess is not preceded by acute symptoms, such as have been 
described. Its appearance is long delayed, and but for the swell- 
ing its presence would not be suspected. 

As the progress of the disease is influenced by the strain and 
injury to which the part is subjected, so abscess, a symptom of 
disease, is more common in those cases in which early and effi- 
cient treatment has been neglected; for the same reason its sub- 
sequent course is directly influenced by the protection that the 
diseased joint receives. 

The danger from abscess is, of course, infection. Occasionally 
the abscess may become infected before an opening forms. Such 
infection may be inferred when the tissues about the abscess are 
hot and sensitive, and when fever is present; but, as a rule, the 
abscess is sterile until the skin is perforated. If the abscess sac 
is small and if drainage is efficient, and especially if communica- 
tion with the joint has been occluded, infection is of slight con- 
sequence. But if before the opening has formed the abscess has 
perforated intermuscular fasciae and has extended between the 
layers of muscles in various directions, infection is likely to cause 
severe local and constitutional symptoms. The thigh becomes 
the seat of an infectious cellulitis, pockets of pus form, which 
cannot be properly drained; hectic, emaciation, and loss of appe- 
tite follow, and if the profuse discharge of pus persists amyloid 
degeneration of the internal organs may result. Such patients 
are said to die of exhaustion, but the cause of exhaustion is an 
infected abscess. 

Treatment. — Admitting that abscess is a symptom whose im- 
portance stands in direct relation to the care that has been exer- 
cised in the treatment of the disease, and that in the better 
class of cases the danger from this source is slight, still it is also 
true that abscess is the chief cause of danger, and almost the 
only cause of death, in hip disease per se. One's views as to the 
treatment are likely to be influenced by the class of cases with 



TUBERCULOUS DISEASE OF THE HIP-JOINT 381 

which he is most familiar. Some surgeons have advocated abso- 
lute non-interference with the symptomatic abscess on the ground 
that in many instances it finally disappears by spontaneous ab- 
sorption, while in other cases the long delay allows the com- 
munication with the joint to close, so that the danger of infection 
after an opening has formed is slight. Finally, that the results 
after non-interference are better than those reported after opera- 
tive treatment. Others insist that all collections of fluid of this 
character should be evacuated as soon as they are discovered, 
because of the danger of infection before an opening forms and 
because of the advantage gained by preventing burrowing of 
pus. Little could be said against this latter course were it not 
that infection is as common after operative treatment as when a 
spontaneous opening forms; the only advantage in favor of the 
artificial opening being that the cavity with which it communi- 
cates should be smaller and more direct than when the fluid 
has undermined the tissues in various directions, but this is offset 
by the fact that at least 20 per cent, of abscesses disappear with- 
out treatment. In fact, as compared with indiscriminate incisions, 
the let-alone treatment should be preferred when proper after- 
treatment cannot be assured. 

It would appear, however, that the middle course, between the 
extremes, is the safest, and especially so, as by far the larger 
number of patients must be treated under conditions that do not 
permit of proper care. In the out-door department of the Hos- 
pital for Ruptured and Crippled abscesses are treated symptom- 
atically. If a swelling appears but remains quiescent and causes 
no symptoms it is not disturbed. If it enlarges, the tension of 
the fluid is relieved by aspiration, which may be repeated as 
required, compression, after the evacuation of the fluid, being 
applied by means of a pad and bandage. If the contents are of 
such a nature that aspiration is impossible, a small incision is 
made, the contents are expressed and the opening is immediately 
closed with one or more sutures. This procedure by which 
infection is avoided may be repeated at intervals. It may be 
employed also when deep-seated abscess within the joint causes 
painful tension. 

If the abscess is of large size, or if acute symptoms are present, 
the child is admitted to the hospital. Here the same general 
principle is followed, but in certain instances it may be thought 
advisable to explore the joint in addition to opening the abscess. 
In such cases the incision must be longer, the wound is then closed 



382 ORTHOPEDIC SURGERY 

with superficial and deep sutures, and a firm dressing is applied. 
This operation, if performed under aseptic precautions, causes 
no disturbance, and it relieves nature from the burden of necrotic 
material which must be an obstacle to spontaneous absorption. 
In many instances the abscess is permanently cured, although 
if the condition that induced it remains unchanged fluid will 
again accumulate, and if so a spontaneous opening will form 
in the line of the incision. This operation is not a radical cure of 
the abscess or of the disease; it is simply a means of thorough 
evacuation for the purpose primarily of accomplishing what the 
aspirator does only in part. If the abscess has become infected 
its contents are completely removed, the wound is then packed 
with gauze, and provision is made for efficient drainage. 

In the treatment of abscesses the injection of iodoform emulsion, 
in connection with the aspiration or incision, has been thoroughly 
tested. The results, as far as the disappearance of the abscess 
was concerned, were not as good as from simple aspiration; and 
as the procedure, being somewhat of the nature of an operation, 
caused the patients some discomfort and anxiety, it was discon- 
tinued. From the clinical standpoint there is little evidence 
that these injections exercise any particular influence upon the 
disease, but, theoretically, iodoform should lessen the infectious- 
ness of the tuberculous fluid, and by local irritation stimulate the 
growth of granulation tissue. There appears to be no serious 
objection to its use. 

The Treatment of Sinuses. — When the disease is active the 
sinuses that serve as drains should not be disturbed. And in 
the advanced cases when disease is quiescent and when the tis- 
sues about the joint are of the peculiar, resistant, "porky" con- 
sistency, active measures, either for the purpose of closing sinuses 
or for the correction of deformity, should be deferred. In many 
instances, however, sinuses persist as tuberculous fistulse, serving 
no useful purpose. In this class the complete removal of the 
infected tissue by excision or by thorough curetting is the most 
effective remedy. The various applications of pure carbolic 
acid, solution of salicylic acid, iodoform emulsion, balsam of 
Peru, and the like are of some service, but thorough removal 
of the disease is the only radical treatment. 

Exploratory Operations. — In certain instances exploratory opera- 
tions may be indicated. If, for example, pain and swelling 
indicate tension within the capsule it may be relieved by a 
small direct incision or the joint may be explored with the 



TUBERCULOUS DISEASE OF THE HIP-JOINT 383 

possibility of finding a localized focus of disease that may be 
removed . 

The joint may be opened by an anterolateral incision, begin- 
ning one inch to the outer side of the anterior superior spine and 
extending downward about three inches. This exposes the line 
of junction between the tensor vaginae femoris and the gluteus 
medius muscles. When these are separated from one another the 
anterior surface of the capsule of the joint is laid bare. If more 
room is required the tensor vaginas feinoris muscle may be divided. 
The capsule is then incised in the line of the neck and through 
the incision the head of the bone may be extruded by rotating 
the limb outward and extending it. By this means the character 
of the disease may be ascertained and in certain instances local- 
ized foci in the neck or in the head of the bone may be removed. 
The wound is then closed or drained as may seem advisable. 
By such intervention the course of the disease may be shortened, 
although cure by this means is unusual. 

Temporary anterior dislocation of the head of the femur by 
means of the anterolateral incision may be of value in acute and 
painful disease. Posterior dislocation for this purpose has been 
performed by Bradford in several cases with satisfactory results, 
the bone being again replaced when the disease had become qui- 
escent. 1 The object of this operation is to remove the opposing 
bones from direct contact, and to relieve the muscular spasm that 
accompanies acute disease. 

Exploratory operations may be of special value in the later 
stages of the disease, to ascertain the cause of long-continued 
suppuration, or of abnormal delay in repair, which may be due 
to detached or adherent fragments of necrosed bone within the 
joint. This point is illustrated by the statistics of 61 cases of 
hip disease treated by excision by Poor. 2 In 15 of these loose 
bone was found in the joint, and in 7 the head of the bone was 
detached. 

In 98 cases investigated by Lehman 3 at the Wiirzburg clinic 
sequestra were present in 20.4 per cent., and in 70 per cent, of 
88 cases treated by Riedel. 4 

An exploration of the joint by one familiar with surgical 
technique should be free from danger, and it may be of much 
value. 

1 Transactions of the American Orthopedic Association, vol. xiii. 

2 New York Medical Journal, April 23, 1892. 

3 Inaug. Diss., Wiirzburg, 1896. 

4 Centralbl. f. Chir., 1893, Bd. xx., Nos. 7 and 8. 



384 ORTHOPEDIC SUB GEB Y 

Excision of the Hip. — The operation of excision is now classed 
as a treatment of necessity in certain cases, usually those in which 
recovery under conservative treatment is considered very doubt- 
ful. For example, when there is progressive failure in health; 
when it is impossible to drain the joint effectively after infection; 
when there is evidence of extension of the disease to the shaft 
of the femur or to the pelvic cavity, or when other serious com- 
plications exist. 

In certain instances the excision may follow an exploratory 
operation; in such cases the anterolateral incision may be em- 
ployed and the neck and head of the bone only may be removed. 
In this operation the diseased tissue is removed as thoroughly as 
possible with the sharp spoon, by scrubbing with iodoformized 
gauze, and by flushing with hot water. If the joint is not in- 
fected it is dried; iodoform emulsion may be injected or the pure 
carbolic acid may be applied, and the various tissues are then 
sewed in layers; pressure is applied, the aim being to secure im- 
mediate union. If this does not take place drainage is employed 
in the usual manner. 

In typical cases the operation is performed because of exten- 
sive disease and infected abscess, and in such instances usually 
the entire upper extremity of the bone to the trochanter minor is 
removed. 

A satisfactory method is that of Koenig. 
An incision about five inches in length is made in a line join- 
ing the trochanter and the posterior inferior spine of the ilium. 
About two-thirds of the length is above and one-third over the tro- 
chanter. The incision is deepened to expose the capsule and the 
surface of the trochanter, from which one removes the insertion 
of the gluteus maximus and the tendons of the medius and mini- 
mus. The muscles are separated in the line of the incision and 
the capsule is widely opened. With a thick, strong knife one 
detaches all the muscular attachments to the anterior margin 
of the trochanter, while the limb is rotated outward, removing, 
if possible, a thin section of periosteum and bone. The same 
process is then repeated on the posterior surface, the limb being 
rotated inward. The trochanter is then removed. 

The acetabular insertion of the capsule, together with the 
adjoining upper border of the acetabulum, is then cut away and 
the neck of the femur is separated from the shaft with a saw 
or chisel. All the diseased parts are then removed, including the 
acetabular wall and adjoining bone, if necessary. The wound 



TUBERCULOUS DISEASE OF THE HIP-JOINT 385 

is partly closed with drainage, and the extremity of the femur is 
placed within the acetabulum, where it should be retained for a 
time by a plaster bandage or Thomas brace provided with trac- 
tion straps. When the patient begins to walk a hip splint or 
other support is used for a time to prevent deformity. One of 
the most efficient supports of this class is the short or Lorenz 
spica, the limb being fixed in an attitude of overextension and 
moderate abduction for many months. 

Another form of incision is that of Rydygier 1 shown in the ac- 
companying illustration. The flap is lifted, the trochanter major 
is cut through and with its attached muscles turned upward. The 



\ 




Rydygier's incision for excision of the hip. 

capsule is then opened 'and the femur is dislocated for inspec- 
tion. All the diseased parts, including the entire acetabulum, if 
necessary, together with the capsule, are then removed. Com- 
plete removal of the acetabulum is indicated when it is perforated, 
a procedure particularly advocated by Bardenheuer. 

The success or failure of excision of the hip as a life-saving 
operation, provided the diseased bone has been removed, is de- 
cided by the after-treatment, and in this, drainage is the great 
essential. The opening must be large and the shaft of the bone 
must be drawn down by efficient traction, so that it may not 
obstruct the opening, and the exuberant granulations must be 

1 Mosetig-Moorhof, Wiener klin. Wochen., No. 20, 1905. 

2 Deutsch. Gesells. f. Chir., XXXV. Kongress, 1906. 

25 



386 OB THOPEDIC S UB GEB Y 

removed from time to time. Phelps lias introduced a valuable 
adjunct in the use of short, glass drainage tubes of large diameter, 
even up to one and one-half inches. Through such a tube or 
speculum the gauze is inserted, the opening permitting thorough 
inspection. 

The importance of an open-air life after these operations can 
hardly be exaggerated. The lack of this, the inefficiency of the 
after-treatment in securing proper drainage, and the postponement 
of the operation until amyloid changes are advanced explain the 
unsatisfactory character of the results. 

The functional results after excision in this class of cases are 
not as good as those that may be obtained when the operation has 
been performed at an earlier period. If motion continues free the 
joint is usually insecure. In many instances there is upward 
displacement of the shaft of the femur upon the ilium with con- 
sequent flexion and adduction deformity, while in a third class of 
cases a movable joint of sufficient strength may be preserved. 
The ultimate shortening is considerably greater than after con- 
servative treatment. This is accounted for by the upward dis- 
placement of the femur and by the removal of the two epiphyses 
of its upper extremity. 

In a period of twelve years, 1888 to 1899, inclusive, 149 opera- 
tions of excision were performed at the Hospital for Ruptured and 
Crippled. During this time 1283 cases of hip disease were treated 
in the wards and 1870 new cases were recorded in the out-patient 
department. Thus the operation was performed in 11.6 per cent, 
of those in the hospital, but the relative frequency of the opera- 
tion in the entire number of patients under treatment was con- 
siderably less than this. 

One hundred and twenty-one of these operations of excision, 
or those performed prior to 1897, have been carefully analyzed 
by Townsend. 1 The 121 operations were performed on 119 
patients, in two instances both hips having been operated upon. 
In 113 abscesses or sinuses were present, in most instances 
infected. In 5 cases the spine was involved as well as the hip; 
in 2 instances the knee; in 2 the tarsus; in 3 the ilium. In 
24 the anterior incision was employed, in 97 the posterior. 
In 18 instances the acetabulum was seriously diseased, and in 10 
osteomyelitis of the shaft of the femur was present. This 
indicates the character of the disease in the cases operated 
upon. 

1 Medical News, June 26, 1897. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



387 



In 99 of the 119 cases the later results of the operation were 
ascertained. Of these 52 were dead and 47 were living. Of the 
52 deaths 9 were due directly to the operation, shock;' 28 were 
caused by exhaustion (persistent suppuration); 9 by tuberculous 
meningitis; 7 by other causes. Thirty-seven deaths occurred 
within six months and 10 others within one year of the operation. 
Of the 47 patients living at the time of the investigation, 26 were 
cured. Of the remaining number about one-half were in poor con- 
dition, so that recovery could not be expected. It is evident that 
in a large proportion of the cases the operation was unsuccessful 
as a life-saving measure, since suppuration persisted. The func- 
tional results in these cases are shown in the following table: 

Table Showing Shortening, Motion, Number of Sinuses Present, 
and Angle of Greatest Extension in Forty-seven Cases of 
Excision. (Townsend.) 











Angle of 






No. 


Time since 


General 


Sinuses 


greatest 


Motion in 


Shortening 




operation. 


condition. 


present. 


extension. 


degrees. 


in inches. 


1 


6% years 


Good 


3 


150 





2V, 


2 


6% " 


Fair 


1 


135 





4 


3 


6 


Good 





180 


100 


3 


4 


Wk " 


•' 





180 


35 


3 


5 


m " 


Fair 





145 


10 


4 


6 


&A " 


Gond 


1 


165 





1% 


7 


5 







155 


5 


2 l A 


8 


4Ji " 




3 


160 





m 


9 


4^ " 


" 





160 





2% 

IS 


10 


4J4 " 







165 





11 


4 


" 





150 





12 


4 


Poor 


4 







13 


S% " 


Good 





155 





14 


3% " 


" 





160 


30 


1 


la 


3 


Poor 


1 


165 





If 


16 


2 


Fair 


2 


145 


30 


17 


2 


(iood 










18 


2 


Fair 


1 


170 





A 


19 


2 


Good 





150 





3 


20 


IK " 


" 





175 




A 


21 


IX " 







165 


30 


A 


22 


% •• 


" 





150 





1 


23 


" 





150 





v i 


24 


V/ 4 " 


" 


1 


180 





25 


1% " 


Fair 


6 


1/5 


15 


i 


26 


1 


Poor 


•> 


165 





2^ 


27 


1 


Good 





170 





1% 


28 


1 


" 





155 





1 


29 


1 







175 





A 


30 


1 


Poor 





180 


10 


1U 


31 


11 months 




3 


170 





% 


32 


10 







180 


40 


w x 


33 


10 


Good 


3 


165 





X A 


34 


10 







160 







35 


10 


•' 


1 


165 





l 2 


36 


10 


Poor 


1 


161) 





H 


37 


10 


Good 


3 


155 


10 


i'i 


3S 


9 




1 







1 


39 


9 











40 


9 


Poor 


1 


170 







41 


9 


Fair 


3 






l 2 


42 


8 


Good 





ISO 


130 


S 


43 


8 




o 


180 




44 


8 " 


Poor 


1 


165 


io 


X 


45 


7 


" 










46 


7 


Good 





180 


10 


VA 


47 


7 







160 


70 


Va 



388 ORTHOPEDIC SURGERY 

Lovett 1 has reported the results of 50 excisions in a similar 
class of cases at the Boston Children's Hospital, 1877 to 1895. 
The number of patients actually treated in the wards of the hos- 
pital is not stated, but 1100 cases were recorded as having been 
under treatment during this time, a percentage of excisions of 
4.5 of the total number. In 8 of the cases osteomyelitis of the 
femur was present, and in 15 the acetabulum was perforated. 
The ultimate mortality was about 50 per cent. 

Poor 2 has reported the results in 65 cases operated upon at 
St. Mary's Hospital, New York, with a final mortality of about 
34 per cent. In 21 cases osteomyelitis of the shaft of the femur 
was present. In 11 cases there was perforation of the acetabulum, 
and in 9 of these the opening communicated with an intrapelvic 
abscess. 

These statistics are quoted to illustrate the relative efficiency 
of late excision. The extent of the lesions in some of the cases 
shows that recovery would have been impossible without opera- 
tion, and its failure to relieve the symptoms in so many instances 
is sufficient evidence that it was postponed too long. Under 
proper conditions for treatment excision of the hip is almost 
never required, but in hospital practice it should be performed 
oftener and earlier in the course of the disease. 

Amputation. — Amputation at the hip should follow excision 
when suppuration persists and when the condition of the patient 
does not improve, provided the internal organs are not hopelessly 
diseased. The operation of amputation after complete excision is 
a simple procedure and it should not be attended with great danger. 

Reduction of Deformity in Resistant Cases. — The various methods 
of reducing deformity during the active stages of the disease have 
been described, and the importance of preventing deformity 
throughout the entire course of treatment has been insisted on. 
At the present time, for one reason or another, deformity from 
this cause is very common, either because its importance is not 
appreciated or because it is considered as a necessary concomitant 
of the disease, treated by apparatus, as it is in the natural cure. 
At all events, in many instances it is allowed to persist until the 
accommodative changes about the diseased joint have so fixed the 
limb in the deformed position that greater correcting force is 
required than can be applied by the weight and pulley or by 
other method of traction. 

1 Transactions American Orthopedic Association, vol. x. 

2 New York Medical Journal, April 23, 1892. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 389 

In this class of cases, in which the muscles are structurally 
shortened and in part transformed to fibrous tissue, and in which 
the anterior wall of the capsule has become retracted and adherent 
to the surrounding parts, forcible reduction under anaesthesia, or 
osteotomy, may be required. If the disease is quiescent or cured, 
if the head of the femur or what remains of it is' in the normal 
position, and if a fair range of motion remains, gradual forcible 




Extreme deformity after hip disease, showing the attitude before operation. 
(See Figs. 264 and 268.) 

reduction after division of the bands of fascia or the muscles 
that hold the limb in the deformed position is advisable. 

In all cases in which the head of the bone is destroyed the 
aim should be to secure an anterior transposition of the upper 
extremity of the femur, and to secure this result one proceeds 
as in reducing or transposing the congenitally displaced hip — 
by longitudinal traction, by forcible abduction, combined with 
massage of the adductors, and, finally, by gradual extension — 



390 



OB THOTEDIC S UB GEB Y 



preceded usually by division of the resistant parts about the 
anterior superior spine. The limb is then fixed by a Lorenz 
spica in an attitude of moderate abduction and overextension. 
Later the abduction is lessened, but the overextended position 
is maintained for many months, and is assured by passive move- 
ments after the support is removed. Forcible reduction in cured 
or quiescent cases is practically free from danger. 

The Correction of Deformity by Femoral Osteotomy. — If the 
deformity is fixed by bony anchylosis or by firm, fibrous adhesions 
within the joint; or if it is feared that violence may stimulate 
dormant disease; or if there is such a degree of upward displace- 
ment of the femur upon the pelvis that the deformity is likely to 
recur after replacement, it is better to correct the deformity by an 
osteotomy of the femur. 




The favorite attitude in recumbency. (See Fig. 263.) 

The patient having been prepared for operation, is turned upon 
the side and a sand-bag is placed between the thighs. A small 
osteotome, about the shape of a lead-pencil, of which one extremity 
is flattened to a cutting edge (Vance's instrument), is pushed 
directly through the soft parts to the femur at a point about two 
inches below the apex of the trochanter. It is turned until its 
cutting edge is at the right angle to the shaft and it is then driven 
through the cortical substance of the bone. When it has pene- 
trated at one point it is withdrawn, and adjoining portions are 
cut until about half the circumference is divided, when with 
slight force the bone may be fractured. If the deformity is of 
long standing, division of the contracted tissues in the adductor 
region and below the anterior superior spine may be required. 

The limb is then drawn down to complete extension and mod- 
erate abduction, and the body and limb are encased in a plaster- 
of-Paris spica bandage, which should remain in position for 



TUBERCULOUS DISEASE OF THE HIP-JOINT 



391 



Fig. 265 



several months, although the patient may be allowed to bear 
weight on the limb a few weeks after the operation. The long 
may be replaced by the short spica at the end of two months. 
This latter or some similar appliance should be used until tests 
show that there is no longer danger of recurrence of the deformity. 

The advantages of the subcutaneous 
method are simplicity and freedom from 
danger. No dressings are required, ex- 
cept a pad of gauze over the minute 
opening; thus the limb may be firmly held 
by the plaster bandage. If there is anchy- 
losis between the femur and the pelvis no 
support will be required after the bone 
has united, but if there is motion in the 
joint some fixative appliance should be 
employed for a time to prevent recur- 
rence of a part of the deformity. 

Prognosis. Mortality.— The direct mor- 
tality of hip disease is due almost entirely 
to the immediate or remote effects of ab- 
scess. This is illustrated by the statistics 
of Bruns, in which the mortality from all 
causes of the non-suppurative cases was 
23 per cent, as compared with 52 per 
cent, in those in whom suppuration was 
present. 

The mortality among the patients 
treated at many of the German clinics is 
much higher than in the corresponding 
class in this country. 

At Tubingen, according to Wagner, 1 it 
was 40 per cent. 

At Kiel, according to Mummelthy, it 

„ aq rr\ j. • ±1 After correction oy osteotomy 

was 46.59 per cent, in non-operative cases a nd division of the contracted 
and 53.96 per cent, in operative cases. ^ le 2 4 1 ( ) Gibney " ) < SeeFi s s - 240 

At Marburg, according to Marsch, it 
was 35 per cent, in non-operative cases and 40.4 per cent, in 
operative cases. 

At Heidelberg, according to Huismans, 2 it was 46.6 per cent, 
in non-operative cases and 58 per cent, in operative cases. 




Beit. z. klin. Chir., 1895, Bd. xiii. 

Quoted by Binder, Zeits. f. Orthop. Chir., 1889, Bd. vii., H. 2 und 3. 



392 ORTHOPEDIC SURGERY 

At Zurich, according to Pedolin, 1 it was 37.7 per cent, in non- 
operative cases and 54 per cent, in operative cases. 

At Vienna, according to Prendlsburger, 2 it was 17 per cent, 
in all classes. 

At Gottingen, according to Koenig, 3 40.3 per cent. 

In a total of 636 cases treated by conservative methods by Rabl, 
1859 to 1894, definite results were ascertained in 519 ; 4 335 were 
hospital cases. Of these 216 were cured, 64.4 per cent.; 70 died, 
20.8 per cent., and 49, 14.4 per cent., were still under treatment; 
184 were treated as out-patients. Of these, 132 were cured, 
71.5 per cent.; 35 died, 19.2 per cent., and 17, 92 per cent., re- 
mained under treatment. 

In 288 cases treated at the Hospital for Ruptured and Crippled, 
New York, reported by Gibney, 5 the death-rate was 12.5 per cent. 

In private practice the statistical reports of final results show 
the death-rate to be extremely small. C. F. Taylor, 6 94 cases, 
including 24 in which suppuration was present, 3 deaths. 
L. A. Sayre, 7 212 cases, 5 deaths. Lorenz, 8 60 cases, with 3 
deaths. 

In the clinics of this country the death-rate has been estimated 
to be from 10 to 15 per cent., a rate of mortality much lower 
than that reported from those abroad. This is accounted for in 
part by the fact that patients are of a better class and in part 
because they receive earlier and more efficient mechanical pro- 
tection. 

The causes of death, according to Wagner's statistics of 124 
cases, were as follows: 

Hip disease 35 

General tuberculosis 37 

Tuberculous meningitis 13 

Tuberculosis of the lungs .... 11 

Acute miliary tuberculosis 5 

Amyloid degeneration 8 

Septic infection 12 

Intercurrent disease 3 

124 

Thirty per cent, of the deaths occurred in the first year of the 
disease, 26 per cent, in the second year, and 20.4 per cent, in the 
third year. 

i Centralbl f. Chir., July 25, 1896, No. 30. - Loc. cit. 

3 Koenig, Das Hoeftgelenk, Berlin, 1902. 

4 Zur Conserv. Behand. der tuberculosen Knochen und Gelenksleiden, J. Rabl, Leipzig 
und Wien, 1895. 

5 New York Medical Journal, July and August, 1877. 

6 Boston Medical and Surgical Journal, March 6, 1879. 
' New York Medical Journal, April 30, 1892. 

s Wiener Klinik, 1892, 10 and 11. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 393 

The percentage of recovery was 65 per cent, of those in the 
first decade of life, 56 per cent, of those in the second, and but 
28 per cent, of those in the third decade. 

The causes of death in 50 cases among 778 patients treated at 
the New York Orthopedic Dispensary and Hospital during the 
years 1877 to 1882 were: 1 

Tuberculous meningitis 20 

Amyloid degeneration 5 

Exhaustion. 3 

Tuberculosis of the lungs '. . . . 3 

Tuberculous peritonitis 1 

Septicaemia 1 

Convulsions 1 

Unknown 16 

50 

Of 96 deaths recorded at the Alexandra Hospital, London (a 
mortality of about 26 per cent, of the cases treated), the causes 
were 

Tuberculous meningitis 16.1 per cent. 

Albuminuria and dropsy 20.8 

Tuberculosis of the lungs 8.3 " 

Exhaustion 9.4 " 

Erysipelas and pyaemia 3.1 " 

After operation 9.4 " 

Intercurrent diseases 7.3 " 

Unknown 25.0 

100.0 " 

The direct mortality of hip disease should include all deaths 
due to operation, those caused by exhaustion, and amyloid degen- 
eration, which is almost always the result of profuse suppuration 
secondary to pyogenic infection. Tuberculous meningitis, a com- 
mon and apparently an unavoidable cause of death, is not neces- 
sarily a complication of the local disease, except in so far as a 
lowered vitality may predispose the patient to it, since it may 
have been due to new infection or induced by the primary focus 
which preceded the tuberculosis of the hip. 

It is believed that operative interference is sometimes the direct 
cause of tuberculous meningitis, and it is of interest in this con- 
nection to note that 20 of 50 deaths, or, rather of 34, in which the 
cause of death was known (58 per cent)., were due to this com- 
plication among the cases treated at the New York Orthopedic 
Dispensary and Hospital, where no operations were performed. 2 
While of 52 deaths in a total of 99 cases treated at the Hospital 
for Ruptured and Crippled, in which excision was performed, 
but 9 were caused by tuberculous meningitis. 3 

1 Shaffer and Lovett, New York Medical Journal, May 21, 1887. 

2 Ibid. 

3 Townsend, Medical News, June 26, 1896. 



394 ORTHOPEDIC SURGERY 

The normal death-rate among cases under fair hygienic condi- 
tions is illustrated by statistics from the Hospital for Ruptured 
and Crippled at a time when no operative or mechanical treat- 
ment was employed. 1 This was 12.5 per cent.; 4.5 per cent, 
from exhaustion, 4.5 per cent, from amyloid degeneration, 1.75 
per cent, from tuberculous meningitis, 1.75 per cent, from inter- 
current diseases. 

Thus nearly 75 per cent, of the deaths were due more or less 
directly to suppuration. 

Functional Results. — In a certain proportion of cases perfect 
function may be retained, the proportion depending upon the 
extent of the disease, and upon the timeliness and efficiency of 
the treatment. 

In a total of 280 cases from the private practice of Dr. L. A. 
Sayre, 2 in which the final results were known, 73, or 26 per cent., 
recovered with perfect motion, and 120 or 42 per cent., retained 
good motion. These results are extraordinarily good, very much 
better than any others that have been reported, and, of course, 
far better than may be expected in the ordinary class of cases. 

The effect of mechanical treatment and of the various measures 
employed for the correction of deformity is well illustrated in 
two series of ultimate results in cases treated at the Hospital for 
Ruptured and Crippled, reported by Gibney. 3 In the first series 
of 80 cases no mechanical or operative measures were employed, 
the treatment being simply hygienic and symptomatic; the re- 
sults, therefore, represent natural cure under proper supervision. 
The duration of the disease was three years in 23; three to six 
years in 28; six to ten years in 16, and fifteen years in one case. 

In 35 cases the shortening was two inches or more, and in 
nearly every case there was more or less deformity, viz. : 

In 2 there was flexion to 90° 

HO 

120 

135 

"19 145 

" 18 " " " 150 

" 11 " " " 160-170 

In 4 no estimate was made. Distortions other than flexion 
are not specified. 

In 12 instances motion was retained of from 15 to 90 degrees. 

1 Gibney, New York Medical Record, March 2, 1878. 

2 New York Medical Journal, April 30, 1892. 

3 Loc. cit. 



TUBERCULOUS DISEASE OF THE HIP-JOINT 395 

In the second series 1 of 107 cured cases, mechanical and opera- 
tive treatment was employed, although the protection assured 
was in many instances far from efficient. In many of these cases 
the disease was in an advanced stage, and deformity was present 
in more than half of the number when treatment was begun, and 
yet all of them recovered without marked flexion and presumably 
without adduction, as this deformity is not mentioned. 

No flexion 47 

Flexion of 10° 30 

" of 10-20° 20 

" of 20-30° 10 

Perfect motion was retained in 13 

Good ' 22 

Limited " " " " 41 

There was anchylosis in 31 

In 69 cases the shortening was one inch or less, 35 having no 
shortening. In 38 it was more than one inch. 

As has been stated, the mechanical treatment in these cases 
was not sufficiently effective to prevent deformity, and to attain 
these results osteotomy with or without division of contracted tis- 
sues was performed in 19 cases, forcible correction with or without 
tenotomy in 30 cases, and in 4 cases the joint was excised. 

If the joint has been actually invaded by disease so that a part 
of its articulating surface has been destroyed, motion must be 
impeded both in area and quality. In such cases the joint is 
somewhat weakened, and it is often sensitive, although in many 
instances not to the extent of interfering seriously with the ability 
of the patient. In this class discomfort in damp weather or pain 
on overexertion is experienced, symptoms similar to those com- 
plained of by rheumatic subjects. 

Simple shortening, due to retardation of growth, unaccompa- 
nied by deformity, is of comparatively little importance. Firm 
anchylosis in a symmetrical position ensures a strong and useful 
limb, the flexibility of the lumbar region compensating for the 
loss of motion at the joint. In such cases the disability may 
be very slight, and the effect of the loss of motion may be more 
apparent in the sitting than in the erect posture, for the patient 
must, as it were, sit upon his back, an attitude which perceptibly 
reduces the sitting height. 

Flexion, if it be slight, does not cause disability, but flexion 
of more than 30 degrees increases the lumbar lordosis and makes 
the buttock prominent, the deformity so characteristic of the 
natural cure (Fig. 207). Great flexion, for example, of 60 or 90 

1 Gibney, Waterman, and Reynolds, Trans. Amer. Orth. Assoc, 1898, vol. xi. 



396 ORTHOPEDIC SURGERY 

degrees, causes an exaggerated lordosis which is almost alwsay 
a source of pain or discomfort to a patient who is obliged to stand 
much of the time. 

Abduction is of no importance unless it is considerable. It 
serves in most instances as a compensation for actual shortening 
of the limb. 

Adduction, on the other hand, which necessitates an upward 
tilting of the pelvis in order to restore the parallelism of the limbs, 
is the most disastrous of all the distortions, since it causes a prac- 
tical shortening often greater than that due to the destructive 
effects of the disease. 

The motion that is retained after recovery from hip disease is 
usually considered as the test of successful treatment. This is 
by no means the fact, for in many instances motion is preserved 
because the joint is destroyed and because what remains of the 
upper extremity of the femur is supported by the tissues on the 
dorsum of the ilium — a form of pathological dislocation. 

In such cases deformity is almost always present, and the 
support is insecure. 

Deformity is far more disabling than loss of motion, and the 
best safeguard against final deformity is to prevent it during 
treatment, and to retain as far as may be the joint surfaces in 
proper relation to one another. Whatever motion is preserved ' 
will then be of service to the patient, and if anchylosis follows 
the result may still be classed as good. 

Deformities of Other Parts Caused by Hip Disease. — Deformities 
of other parts are sometimes observed as secondary results of hip 
disease, most often in cases that have not received proper treat- 
ment. In the spine an exaggerated lordosis as a compensation 
for flexion is not uncommon, and lateral curvature may follow 
distortion of the pelvis caused by adduction. In the limb knock- 
knee may follow persistent adduction of the thigh, or it may be 
an effect of laxity of the ligaments without such distortion. 
Another deformity is genu recurvatum. This is apparently caused 
by long-continued disuse of the limb, and by the use of apparatus 
in which the knee has not been properly supported. If is sup- 
posed to be one of the effects of traction, but it is also observed 
in cases in which traction has never been employed. In cases in 
which the muscular atrophy that follows limited motion and long- 
continued disuse is great, laxity of the ligaments of the knee-joint 
is common, and not infrequently subluxation of the tibia also. 
A slight degree of equinus with accompanying exaggeration of the 



TUBERCULOUS DISEASE OF THE HIP-JOINT 397 

arch is not uncommon among patients who have been treated by 
the traction apparatus, in which the foot is pendent and in which 
the toes are often inclined downward to guide the brace in walking. 
Practically speaking, all these secondary deformities may be 
avoided by proper supervision of the patient during the period 
of treatment. 

As a rule, patients who have recovered from hip disease finally 
discard all apparatus, or at most use only a cane as a support, 
and many prefer to walk habitually on the toe rather than to 
equalize the length of the limbs by a high shoe. 

By far the larger number of this class, having accommodated 
themselves to whatever weakness and distortion may be present, 
are able to undertake the ordinary occupations of life. Of the 
patients cured at the New York Orthopedic Dispensary and 
Hospital in the report already referred to, in whom the final 
results as regards motion and symmetry were certainly not above 
the average, it is stated that there was not a single individual 
who was incapacitated from doing a full day's work at his or her 
trade or occupation. None used crutches and but one used a 
cane. 



CHAPTER VIII. 

NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT. 

The relative frequency and importance of the various affec- 
tions of the hip-joint that cause disability are indicated by the 
following statistics of Koenig's 1 clinic at Gottingen: 

Tuberculous disease 568 = 75 per cent. 

Infectious arthritis following typhoid fever : 

Scarlatina and the like 110' 

Gonorrhoeal arthritis 30 

Arthritis deformans 22 

Injuries 11 i 

<-,,,. , a r = + 25 per cent. 

Contractions, cause unknown 6 

Coxa vara 5 

Tumors 2 { 

Pysemic suppuration 3J 

757 

Several of the affections enumerated are very uncommon in 
childhood, while injury and coxa vara are relatively more im- 
portant. Coxa vara and fracture of the neck of the femur in 
early life are considered in Chapter XV. 

Traumatisms at the Hip-joint. 

It is probable that injury at the hip-joint, caused by falls or 
strains, may induce congestion about the epiphyseal cartilage of 
the head of the femur. In this class of cases there is usually 
discomfort at night after overexertion, "growing pain," and 
there may be a limp and restriction of motion. These symptoms 
may disappear in a few days or they may recur from time to 
time. If the injury is more severe there may be local sensitiveness 
and even swelling — synovitis. This congestion, with the lessened 
local resistance induced by it, may be a predisposing cause of 
tuberculous disease. It is probable, also, that cases of this type 
are sometimes mistaken for hip disease and go to swell the number 
of perfect functional results that are attained by one or another 
system of treatment. 

Treatment. — All cases of this class require careful treatment 
and supervision. Strains or other injuries in young children are 

1 Das Hoeftgelenk, Berlin, 1902. 



NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT 399 

best treated by a supporting bandage and by rest in bed until 
the symptoms disappear. If the sensitive condition persists, 
protective treatment by a brace, preferably the ordinary traction 
hip splint, or by a short plaster bandage, should be employed, 
the diagnosis being reserved until it is made clear by the progress 
of the case. Chronic synovitis of the hip-joint, especially in 
the adolescent or adult, unless it is a result of severe injury, is 
usually tuberculous in character. 

Fracture of the neck of the femur, epiphyseal separation, and 
coxa vara are considered in another section. 

Acute Infectious Arthritis — Acute Epiphysitis at the Hip-joint. 

Acute epiphysitis, caused by infection with pyogenic germs, is 
not uncommon in infancy and early childhood, and it often passes 
as a form of acute tuberculous disease. Of fifty-two cases in 
which but a single joint was involved the hip was affected in 
twenty-six. 1 In some instances it is induced or favored by in- 
jury, in others it is secondary to an infected wound, and it may 
follow pneumonia or one of the exanthemata. 

Symptoms. — The symptoms are of sudden onset, accompanied 
usually by high fever and prostration. The hip becomes swollen, 
hot, and sensitive both to motion and pressure. 

Treatment. — The treatment is early and free incision and 
efficient drainage, the limb being afterward supported by some 
form of splint. The suppuration ordinarily persists for several 
months; the epiphysis is usually destroyed in whole or in part, 
and in consequence the joint becomes somewhat loose and flail-like 
(Fig. 266). Many of these cases seen in later years, but for 
the history and the scars about the joint, might be mistaken for 
congenital dislocation. In certain instances the symptoms are 
less acute and the diagnosis from tuberculous disease can be 
made positively only after a bacteriological examination of the 
fluid that may be removed from the joint by aspiraton. 

In the class of cases in which the disease is confined to one 
joint and in which the shaft of the bone is not involved, the prog- 
nosis is good if the pus is thoroughly evacuated. In twelve 
cases treated at the Hospital for Ruptured and Crippled there 
were three deaths. 2 The prognosis as to function under these 
conditions is much better than in tuberculous disease. 

1 Townsend, American Journal of the Medical Sciences, January, 1890. 

2 Townsend, loc. cit. 



400 ORTHOPEDIC SURGERY 

After recovery the joint should be supported for a time to 
prevent upward displacement. If the head of the femur has 
been destroyed there is usually upward and backward displace- 
ment. This induces flexion and adduction of the limb and great 
disability. In such cases one should, under anaesthesia, force the 
femur forward to the neighborhood of the anterior superior spine 
and to fix it there for a long period by the application of a Lorenz 
spica bandage applied with the limb in an attitude of abduction 
and hyperextension. The operation is in detail similar to the 
Lorenz method for replacing the congenital dislocation. (See 
Congenital Dislocation of the Hip.) 

Subacute Arthritis. 

In the forms of arthritis that may complicate infectious dis- 
eases several joints are usually involved, and the affection is 
often subacute in character. 

Undoubtedly there are mild cases of infection at the hip-joint 
terminating in partial or complete recovery without operation. 
In such cases, which are usually classed as rheumatism, there is 
usually some infiltration about the hip, flexion deformity, limita- 
tion of motion, and pain or discomfort referred to the affected joint. 
A satisfactory treatment is the application of ichthyol ointment 
in a strength of about 25 per cent., the joint being fixed by a 
posterior wire splint or light Thomas hip brace. 

Spontaneous Dislocation of the Hip-joint. 

If the hip-joint becomes distended with fluid the capsule may 
be ruptured and sudden displacement may occur. 

Degez 1 has collected from literature seventy-nine cases of this 
character. The displacement occurred in the course of the fol- 
lowing diseases: 

Typhoid fever 32 

Rheumatism 24 

Scarlatina 13 

Variola 3 

Gonorrhceal arthritis 3 

La grippe 2 

Erysipelas 1 

Eruptive fever 1 

Such accidents 2 may be guarded against by preventing flexion 
and adduction of the limb and by evacuation of the fluid that 

• l Revue d'Orthope'die, January 1, 1899. 
2 Graff, Deutsche Zeits. f. Chir., February, 1902. 



NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT 401 



distends the joint. The femur should be replaced as soon as 
possible before it has become fixed by adhesions and contrac- 
tions. Even in this class of cases, in which treatment has been 
delayed for months, by means of preliminary traction and by 
the use of manual force, as in the reduction of congenital disloca- 
tion, one may succeed in replacing the femur. In cases of long 
standing the acetabulum is filled with 
new material, which must be removed FlG- 266 

by the open method before replacement 
is possible. As an alternative operation 
one may force the head of the femur into 
the anterior position and fix the limb, for 
several months, in the attitude of exten- 
sion and adduction. If the outward rota- 
tion of the foot is excessive, or if a ten- 
dency toward adduction persists, a sec- 
ondary osteotomy of the shaft below the 
trochanter minor may be performed. 
However early reduction is accomplished, 
limitation of motion is to be expected, and 
in many instances absolute anchylosis. 
On this account the limb should be sup- 
ported for a time in proper position in 
order to prevent deformity. 

Gonorrheal Arthritis. 

Gonorrhceal arthritis of this joint is an 
affection not uncommon in adult life, and 
in its symptoms and effects it may re- 
semble tuberculous disease or perhaps 
more closely osteoarthritis. The treat- 
ment of infectious arthritis in general is 
discussed elsewhere. Deformity should 
be corrected by rest in bed with traction, 
and protective treatment should be em- 
ployed while the sensitiveness persists. 
The short spica plaster bandage, if properly applied, is a satisfac- 
tory support. 

Extra-articular Disease. 

Occasionally tuberculous disease, or other form of destructive 
ostitis, may begin in the neighborhood of the trochanter major. 

26 




The later effect of acute epi- 
physitis of the right hip at three 
months of age. The scar is 
shown. 



402 ORTHOPEDIC SURGERY 

The symptoms are local pain, sensitiveness, and swelling of the 
soft parts. Later thickening and irregularity of the underlying 
bone become evident. 

The symptoms are limp and discomfort. If the disease in- 
volves the capsule or is sufficiently acute to cause sympathetic 
congestion of the joint, there may be limitation of motion; but, 
as a rule, this is slight or absent. In many instances the focus 
in the bone may be demonstrated by an #-ray negative. When 
the disease is tuberculous or of the subacute type, abscess in the 
trochanteric or gluteal region may be the first indication of disease. 

The treatment is prompt removal of the focus of disease before 
the joint or the shaft of the femur has become involved. 

Disease of the pelvic bones in the neighborhood of the joint 
may simulate hip disease. The diagnosis is made by the local 
swelling and sensitiveness, and by the freedom of motion in the 
directions not restrained by sensitive tissues that are involved 
in the disease. 

Gluteal Bursitis. — An enlargement of one of the bursa? lying 
beneath the gluteal muscles may cause a rounded, fluctuating 
swelling in the buttock. It may be sensitive to pressure and it 
usually causes a limp and some discomfort on motion, dependent 
upon the degree of inflammation that may be present. Occasion- 
ally the bursitis may be caused by injury, but in most instances 
it is the result of tuberculous infection. The bursa may com- 
municate with a diseased hip-joint, but usually it is a distinct 
and primary affection. 

Iliopsoas Bursitis.— The iliopsoas bursa lies in front of the 
capsule of the hip-joint, extending from the trochanter minor to 
and sometimes over the brim of the pelvis. Not infrequently 
it communicates with the joint. If the bursa is enlarged it forms 
a swelling in Scarpa's space of a somewhat quadrilateral form. 
Sometimes a central indentation indicates the position of the 
iliopsoas tendon. This causes a distinct enlargement of the 
upper and inner aspect of the thigh. It is usually accompanied 
by slight flexion, abduction, and outward rotation of the limb, 
an attitude that relieves the tension on the sensitive part. 
Zuelzer has collected from literature forty-five cases of gluteal 
and fifteen of iliopsoas bursitis. This illustrates the relative 
frequency of the two affections. 1 

Simple bursitis may be distinguished from disease of the joint 
by the absence of characteristic muscular spasm and general 

1 Deutsche Zeits. f. Chir., Bd. i., H. 1 und 2. 



NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT 403 

limitation of motion. Acute inflammation of a bursa may simu- 
late local abscess. 

Treatment. — Chronic disease of bursse is usually tuberculous 
in character. Aspiration and injection of carbolic acid or iodo- 
form emulsion may be employed as primary measures. As a 
rule, however, incision, drainage, or, if possible, removal of the 
sac is indicated. According to Lund, 1 the iliopsoas bursa may 
be reached easily by a vertical incision between the femoral artery 
and the crural nerve. 

Malignant Disease about the Hip-joint. 

Carcinoma of the upper extremity of the femur is almost always 
secondary to a primary tumor of another part of the body. Sar- 
coma is far less frequent in this situation than at the knee. The 
character of the disease soon becomes evident in the general 
enlargement of the upper extremity of the thigh, but in the early 
stage diagnosis can be made only by means of the x-ray or by 
exploratory incision. 

Cysts of the Femur. 

In rare instances cysts, caused apparently by congenital inclusion 
of a displaced portion of epiphyseal cartilage, may cause enlarge- 
ment, weakening, and deformity of the upper extremity of the femur. 
One case, in a boy thirteen years of age, was treated at the Hospital 
for Ruptured and Crippled. The symptoms were discomfort, 
limp, and outward bowing of the upper third of the femur. Cure 
followed its removal. Of 24 cases reported 13 were of the upper 
extremity of the femur, 1 of the lower end, 3 of the upper 
extremity of the tibia, 3 of the upper portion of the humerus. 
The affection is usually discovered during the growing period, 
injury being an exciting cause. In some instances spontaneous 
fracture occurs. 2 

Cysts may be caused also by localized osteomyelitis of a mild 
character. 

Arthritis Deformans. 

Osteoarthritis of the Hip-joint.— Osteoarthritis is not infre- 
quently confined to the hip-joint. In this form it is practically 

1 Boston Medical and Surgical Journal, September 25, 1902. 

2 Mikulicz, Zeits. f. Chir., November 19, 1904. 



404 ORTHOPEDIC SURGERY 

an affection of adult life or old age (malum coxse senile). It is far 
more common in males than in females. It is characterized in 
its later stages by disappearance of the cartilage covering the head 
of the femur and by an eburnation and progressive destruction, or 
wearing away, of the underlying bone with formation of ecchon- 
droses about the junction of the femur with the acetabulum, 
which become ossified into irregular masses of bone. In the 
early stage of the affection the fluid within the joint may be in- 
creased in amount, but later it is diminished in quantity and 
changed in quality as the synovial membrane becomes trans- 
formed in part to fibrous tissue. The etiology of the affection is 
discussed elsewhere. (See page 279.) 

Symptoms. — The early symptoms are usually subacute in char- 
acter. They are neuralgic pain in the limb, "sciatic rheumatism," 
stiffness on changing from rest to activity, and sensitiveness to 
direct pressure on the joint, so that the patient often lies habitually 
on the other side. The movements of the joint become somewhat 
restricted, and the patient notices that he cannot take a long step 
or ride with comfort. In many instances creaking or grating in 
the joint is noticeable. In advanced stages of the disease there is 
marked thickening about the trochanter which is usually displaced 
upward, owing to the progressive changes in the head and neck of 
the femur. The limb is shortened and it is often distorted, usually 
in an attitude of flexion and adduction, and marked atrophy is 
apparent, appearances that, but for the history, might be mis- 
taken for fracture of the neck of the femur. So also in the earlier 
period of the disease the limp, the pain, and restriction of motion 
with the attendant atrophy may simulate very closely tuberculous 
disease of a subacute type. 

The progress of the disease may be slow or it may be rapid. 
It depends in great degree upon the strain to which the part is 
subjected. In this it resembles tuberculous disease. 

Treatment. — In the class of cases in which the disease is con- 
fined to a single joint one may hope to check the progress of the 
destructive process by lessening the strain upon the joint by 
regulation of the patient's habits and occupation, and to improve 
the nutrition of the part by massage and local stimulants. 
Passive motion in the directions of abduction and extension, for 
the purpose of preventing secondary contraction of the muscles, 
is of service also. 

If deformity is present it should be reduced by traction and 
rest in bed. Afterward the symptoms may be relieved by the 



NON-TUBERCULOUS AFFECTIONS OF THE HIP-JOINT 405 

use of a hip brace (Fig. 252) that will remove the weight and 
limit the range of motion, or a support of the character of a Lorenz 
spica of plaster, leather, or other material may be used. In 
extreme cases resection of the upper extremity of the femur might 
be advisable. Lorenz states that he has treated cases satisfac- 
torily by inducing anterior transposition of the head of the femur 
and fixing the limb for a time in an attitude of extension and 
abduction. In most cases neither the operative nor the brace treat- 
ment is feasible, but the use of a firm flannel spica bandage or 
similar support, combined with the application of cautery, from 
time to time, adds to the comfort of the patient. 



CHAPTER IX. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT. 



-White swelling, tumor albus. 
Tuberculous disease of the knee-joint is next in frequency and 
importance to that of the hip. It is, however, far less dangerous 
to life, and the prognosis, as regards function, is much better than 
in the former affection. This is explained by the simplicity of 
the joint and by its situation at a distance from the trunk, at the 
junction of two levers of nearly equal length and size. As the 
problem of protection by mechanical means is comparatively 
simple it is more often applied, and in proportion to its efficiency 
the injury is lessened and the tendency to deformity is checked. 




Section of knee-joint at the age of eight years, 
showing the epiphyses of the femur and tibia and their 
relation to the capsule. (Krause.) The centres of 
ossification in the epiphyses of the femur and tibia are 
present at birth. Ossification is completed in each at 
about the twentieth year. 

The range of motion is from slightly more than 
complete extension to about 50 to 60 degrees. In 
complete extension the tibia is rotated outward on the 
femur. In midflexion the laxity of the ligaments per- 
mits a range of inward and outward rotation of about 
2.5 degrees. 



Pathology. — The disease may begin in the epiphysis of the 
femur or in that of the tibia, occasionally in the patella or in the 
head of the fibula, or primarily in the synovial membrane. 

In 547 cases, 1 about two-thirds of which were in adults, treated 
at Koenig's clinic at Gottingen by operative procedures which 
permitted inspection of the joint, 281 (51.4 per cent.) were appa- 
rently examples of primary osteal disease; 266 (48.6 per cent.) 
were primarily synovial. The focus was in the femur in 93 

1 Die Specielle Tuberculose der Knocken und Gelenke, Berlin, 1896. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 407 

instances (33.1 per cent.), in the tibia in 107 (38.1 per cent.), in 
the patella in 33 (11.7 per cent.), and in more than bone in 48 
(17.1 per cent.). 

The examination of a joint permitted by arthrectomy or excision 
cannot be sufficiently thorough to exclude disease of the bone and 
to establish the diagnosis of primary disease of the synovial mem- 
brane, but in 92 instances the opportunity was offered by ampu- 
tation at the thigh, 80 of the patients being adults. This examina- 
tion, presumably thorough, showed the primary disease to be 




Acute tuberculous arthritis of the knee. 



of the bone in 50 cases, while in 35 the synovial membrane 
was apparently the seat of the primary affection. In 17 of 
the 50 cases in which the disease was osteal, the focus was in 
the femur; in 7 it was in the internal condyle, in 6 in the 
external condyle, and it was in other situations in 4 cases. In 
17 the primary disease was of the tibia; in 5 of the internal tuber- 
osity; in 5 of the external tuberosity; in other situations 7. In 



408 



OR THOPEDIC SURGERY 



5 instances the primary disease was of the patella, and more 
than one bone was involved in 11 cases. Nichols 1 states that he 
has examined 120 tuberculous joints of adults and children, after 
excision or amputation, or at autopsy, and in every instance 
primary foci in the bone were discovered. He believes primary 
disease of the synovial membrane to be very uncommon, and 
asserts that examinations are of no particular value as establishing 
the absence of primary osteal disease unless the bones are sawed 
into thin sections. This is the view 
FlG ' 269 generally held in this country, that in 

the great majority of cases the disease 
of the bone precedes the disease in 
the interior of the joint. From the 
clinical standpoint, however, one re- 
cognizes two distinct types of tuber- 
culous disease: one beginning as a 
chronic synovitis of which the early 
symptoms are subacute, a type more 
often seen in adults (Fig. 269); and 
the more common class, in which the 
symptoms of pain, muscular spasm, 
and deformity seem to indicate 
clearly primary disease of the bone. 
The proximity of the active disease 
in the neighborhood of the joint sets 
up a sympathetic hyperemia within 
it, and an accompanying synovitis. 
If the disease is progressive the syno- 
vial membrane becomes thickened 
and adhesions form between its folds 
that gradually lessen the capacity of 
the joint and diminish its mobility. 
When perforation takes place the 
granulation tissue spreads over the surface of the cartilages, destroy- 
ing them in its progress and eroding the underlying bone; or if the 
joint is filled with tuberculous fluid the cartilage may be macerated 
and separated in necrotic shreds. The direct destructive effects 
of the disease are increased by pressure and friction if the joint is 
not protected by mechanical means. The hypertrophied synovial 
membrane and the thickened and diseased capsule explain the 
peculiar elastic resistance on palpation called pseudofluctuation. 

1 Transactions American Orthopedic Association, vol. xi. 




Tuberculous disease of the knee in an 
adult. The synovial type. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 409 

In more advanced cases there is also a reactive inflammation in 
the overlying tissues, accompanied by a formation of fibrous 
tissue that involves the tendons and muscles. These changes 
within and without the joint cause the firm, resistant tumor 
characteristic of "white swelling." 

Etiology. — The etiology of tuberculous disease has been dis- 
cussed in Chapters V. and VII. 

Statistics. — Tuberculosis of the knee-joint is essentially a dis- 
ease of early life, although it is less strictly confined to child! ood 
than is disease of the spine or hip. Sex exercises but little influ- 
ence, and the two sides are affected in nearly equal numbers. 
These points are illustrated by the following table of 1000 con- 
secutive cases treated at the Hospital for Ruptured and Crippled. 1 



Age at Incipiency op Knee-joint Disease. 



1 year or less 

2 years old . 

3 " " . 

4 " " . 

5 " " . 



23 years old 12 



10 " 

11 " 

12 " 

13 " 

14 " 

15 " 

16 " 

17 " 

18 " 

19 " 

20 " 

21 " 

22 " 

Males . 
Females 



45 


24 " 


91 


25 " 


164 


26 " 


84 


27 " 


75 


28 " 


66 


29 " 


74 


30 " 


65 


31 " 


60 


32 " 


46 


33 " 


20 


34 " 


19 


35 " 


17 


36 " 


12 


37 " 


10 


38 " 


20 


39 " 


8 


40 " 


8 


41 " 


8 


50 " 


12 




13 





Right 
Left 



485 
515 



Symptoms. — The general characteristics of tuberculosis have 
been described in the chapters on Pott's disease and hip disease. 
In the description of these affections, however, but little stress 
was laid on local sensitiveness and local swelling, because the 
diseased parts lie at a distance from the surface and are concealed 
by the muscles and other tissues. At the knee, on the other 
hand, the joint is superficial, and even slight effusion changes, 
to a perceptible degree, its contour. If the disease is progres- 

1 These statistics, together with those of tuberculous disease of the joints, other than of 
the hip, -were collected for me by Drs. F. C. Bradner, S. E. Sprague, E. L. Barnett, and 
S. W. Stone, house officers at the hospital, 1900-1901. 



410 



ORTHOPEDIC SURGERY 



sive, sensitiveness to pressure, elevation of the local temperature, 
and infiltration or thickenmg of the tissues are usually present. 

Even when the patients are seen at a comparatively early stage 
in the course of the disease the history of the affection will almost 
always show that it is chronic and progressive in character. The 
importance of establishing this fact has been mentioned in the 
consideration of hip disease, and it may be stated again that a 
chronic painful disease of a single joint, accompanied by a tendency 
to deformity, is, in childhood, almost always tuberculous in 
character. 

The symptoms of tuberculous disease may be classified as 
limp, pain, local heat, sensitiveness and swelling, muscular 
and limitation of motion, distortion and atrophy. 

Fig. 270 




Flexion deformity at the knee-joint, with slight subluxation of the tibia. 



On physical examination one will note the character of the 
limp and the slight flexion of the limb that usually accompanies 
it. The joint is, as a rule, somewhat enlarged, the normal 
depressions about the patella and the prominence of the component 
bones being less accentuated than on the opposite side. There is 
usually slight local elevation of temperature and sensitiveness to 
pressure, varying in degree with the character of the disease. 
In certain cases a degree of effusion is present, sufficient to be 
classed as synovitis, but in most instances the swelling is due, in 
great part, to the hyperemia and thickening of the synovial 
membrane and the capsule, which gives the sensation of elastic 
resistance rather than of actual fluctuation. 

The most important diagnostic sign is limitation of the range 
of motion caused by muscular spasm. The normal range is from 
complete extension, 180 degrees, to a degree of flexion, limited by 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 411 

the apposition of the calf and the posterior surface of the thigh. 
Even in the early stage of disease slight limitation of complete 
extension is present, due to reflex muscular spasm, and usually a 
corresponding limitation of the complete flexion. On sudden 
movements the characteristic reflex contraction of the muscles is 
apparent. In most cases this limitation of motion and consequent 
flexion deformity is well-marked on the first examination. 
Atrophy of the muscles of the thigh and calf, dependent upon 
the duration of the disease and upon the interference with func- 
tion, is present, and this atrophy is more noticeable because of 
the enlargement of the knee. 




After forcible correction, showing the increase of the posterior displacement. 
Drawings from the x-ray photographs of an actual case. 

In certain cases, more often seen in infancy and early child- 
hood, the symptoms are more acute and the progress of the 
disease is so rapid that it may simulate an infectious epiphysitis 
(Fig. 268). 

In another type, apparently a primary disease of the synovial 
membrane, more common in adults, the early symptoms are 
very similar to those of simple chronic synovitis. The joint is 
swollen by a distention of the capsule, pain is not troublesome 
except on jars or sudden twists of the limb, and muscular spasm 
and limitation of motion are evident only after a careful exami- 
nation. In this class, months or years may pass before the 
symptoms become as disabling as in the osteal type of the disease. 

Primary and Secondary Distortions of Knee-joint Disease. — At the 
hip-joint, in which the range of motion is extensive, the deformities 
resulting from disease are somewhat complex, causing, for example, 
apparent shortening or lengthening, according as the limb is ad- 
ducted or abducted. But the movements that the knee-joint per- 
mits are much simpler, and the primary distortion is simply flexion. 
Complete extension of the limb, the limit of normal motion in 



412 ORTHOPEDIC SURGERY 

that direction, brings the joint surfaces into close apposition; 
the ligaments are then tense and no lateral motion is permitted. 
This is the attitude in which the greatest efficiency of the limb 
for weight bearing is assured. When the ability of the knee for 
carrying out its normal weight-bearing function is lessened by 
disease which makes the parts sensitive to pressure and strain, 
the range of extension is lessened and the limb is persistently 
flexed to a greater or less degree, corresponding to the sensitive- 
ness of the joint. The agents that adapt the limb to the habitual 
attitudes are the muscles under the control of tbe nervous system. 
In this sense the primary distortions are due to muscular action, 
but it is certainly not true that these muscles antagonize one 
another, and that the stronger overcoming the weaker cause 
the deformity, since the extensors at this joint are stronger than 
the flexors, and since flexion is the primary deformity at every 
joint which is diseased without regard to the relative strength 
of the opposing muscular groups. 

In disease at the knee-joint, as at other joints, the extremes of 
motion in every direction that the joint permits are limited by 
muscular spasm, but limitation of extension, which is so essential 
to normal use, is at once evident, while limitation of flexion, the 
extreme of which is unessential, is only apparent on examination, 
and it may be absent even. Flexion is, then, the primary distortion 
at the knee, and other deformities may be classed as secondary. 

Secondary Deformities. — Of these the most common is outward 
rotation of the tibia upon the femur. When the limb is fully 
extended the tibia is fixed, but when it is flexed lateral motion is 
possible, and in the attitude of flexion the traction of the biceps 
upon the head of the fibula tends to rotate it upon the femur. 
This deformity is also favored by the use of the limb in the atti- 
tude of outward rotation, which is always assumed when the weak- 
ness or stiffness of the knee-joint is present, and by the secondary 
knock-knee that often accompanies the disease. 

Subluxation or backward displacement of the tibia upon the 
femur is another secondary deformity. When the leg is flexed 
upon the thigh the articulating surface of the tibia glides back- 
ward upon the condyles of the femur. Here it becomes fixed by 
muscular contraction, and later by the secondary changes within 
the joint. If muscular spasm is extreme, this alone may cause 
the subluxation; but there are other factors: one is the destruc- 
tive action of the disease, which is usually most marked at the 
point at which the bones are in contact, and the other is the leverage 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 413 

exerted upon the joint. This is exemplified by the increase of 
the displacement that is often observed when an attempt is made 
to straighten the limb by force, against the resistance offered by 
the contracted tissues on the flexor aspect. The same leverage, 




Untreated disease of the knee-joint involving the shaft of the femur, illustrating the 
hypertrophy of the condyles of the femur, the subluxation and outward rotation of the 
tibia, the atrophy and the characteristic deformity. 

in slighter degree, is exerted when the weight of the distorted 
limb is supported on the heel in the recumbent posture, or when 
the limb is extended in the act of walking, or if the upper extremity 
of the tibia is not supported during the period of treatment by 
apparatus (Fig. 271). 



414 ORTHOPEDIC SURGERY 

Knock-knee (genu valgum) is another secondary deformity. 
This is explained in certain instances by the hypertrophy of the 
internal condyle caused by disease, but it is induced more directly 
by the use of the flexed and somewhat disabled limb in the pas- 
sive attitude of outward rotation. Genu varum is uncommon, and 
it is usually the result of the destruction of a part of the internal 
condyle of the femur or of the tibia, or of irregular epiphyseal 
growth. 

The character and the relative frequency of the deformities are 
indicated by the statistics of Koenig's 1 clinic, of 150 cases of knee- 
joint disease treated by arthrectomy, 128 of these being in children. 
In 94 cases flexion was present; in 50, from a slight degree to 135 
degrees; in 16, from 135 degrees to 90; in 28, to a right angle 
or less. Together with the flexion were combined other deformities 
as follows: Genu valgum in 60 cases; moderate in 42; extreme 
in 18. Genu varum in 1 case. Subluxation of the tibia in 20 
cases. Outward rotation of the tibia in 10 cases. 

As has been stated, the primary deformity of knee disease is 
simple flexion. If the disease is of an acute type this flexion 
increases rapidly. If it is subacute in character, and especially 
if the clinical signs indicate that the disease is primarily of the 
synovial membrane, the progress of the deformity is slow. In 
ordinary cases secondary deformities appear at a later time and 
especially when the disease has reached the destructive stage; 
and they are most marked in patients who have persistently used 
the deformed limb without protection. 

Actual Shortening and Actual Lengthening. — Retardation of 
growth is, of course, not an early symptom of disease; in fact, 
actual lengthening of the limb, due to the irritative effect of the 
disease upon the epiphyseal cartilage of the femur or of the tibia, 
is common. This lengthening, sometimes to the extent of an 
inch or even more, may persist throughout the entire course of 
treatment, but after the cure of the disease a corresponding retarda- 
tion of growth that will more than equalize the length of the limbs 
may be expected. When the disease is of the destructive type 
the ultimate shortening may be considerable; two or more inches 
is not unusual. 

Leusden, 2 in 33 cases under treatment in the clinic at Got- 
tingen, 1896-1898, found slight shortening in 2, equality of 
length in 18, lengthening of the femur on the diseased side in 13. 

In one hundred and sixteen cases of tuberculous disease of the 

1 Loc. cit. - Deutsche Zeits. f. Chir., Bd. li., H. 3 und 4. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 4] 5 

knee the limbs were measured by Berry and Gibney 1 with refer- 
ence to this point. In 72 of these there was actual lengthening 
of the femur, from which it may be inferred that in at least 62 
per cent, of the cases examined the primary disease was of the 
femur. 

In 17 M inch. 

"34 X " 

"15 % " 

"6 .1 

72 = 62 per cent. 

H. L. Taylor, 2 from an examination of 40 cases of tuberculous 
disease of the knee, concludes that the limb is almost always 
longer in the first two years of the disease, usually longer during 
the second two years, but usually shorter when the period of 
growth is completed. The lengthening is in most instances of 
the femur. 

Diagnosis. — Tuberculous disease is a local destructive process 
that is, as a rule, confined to a single joint. This is an important 
point in the differential diagnosis from general or constitutional 
affections like rheumatism, rheumatoid arthritis, and the like, in 
which several joints are involved. The following affections may 
be considered in differential diagnosis. 

Injury of the Knee. — Strains of the knee in childhood are often 
followed by limp and persistent flexion and pain on motion. In 
such cases the onset is sudden and the symptoms usually disap- 
pear quickly under treatment. Synovitis of traumatic origin is 
usually indicative of a more severe injury. When synovitis per- 
sists the diagnosis may be doubtful because tuberculous infection 
may have followed the original injury. This emphasizes the 
importance of the careful treatment and continued observation of 
injuries of this class, especially in weakly children. 

Synovitis. — Chronic synovitis of doubtful origin, which shows 
no tendency toward recovery, is usually tuberculous in character. 

Haemarthrosis. — Effusion of blood into the knee-joint may cause 
inflammatory symptoms during the stage of absorption and 
organization of the clot that resemble those of disease. The 
sudden onset and the personal history of the patient, who may be 
known as a bleeder, will explain the symptoms. (See page 289.) 

Infectious Arthritis. Acute Epiphysitis. — This is of sudden onset, 
attended by the constitutional and local symptoms of acute infec- 
tion. 

1 American Journal of the Medical Sciences, October, 1893. 

2 Transactions American Orthopedic Association, 1901, vol. xiv. 



416 ORTHOPEDIC SURGERY 

Rheumatism. — This, in early childhood, may be confined to a 
single joint, but it is of sudden onset, it is usually accompanied 
by constitutional disturbance, and after a time other joints become 
involved. 

Rheumatoid Arthritis. Osteoarthritis. — Diseases of this char- 
acter, of the monarticular form, are more common in adult life. 
The symptoms are rather "of the rheumatic than of the tuber- 
culous type. 

Charcot's Disease. — Charcot's disease of the knee-joint is char- 
acterized by sudden effusion, by rapid destruction of the joint, 
and consequently by weakness and deformity; but pain is usually 
very slight and muscular spasm is absent. The diagnosis of dis- 
ease of the spinal cord will explain the condition of the joint. 
(See page 290.) 

Sarcoma. — Sarcoma, beginning in or near the epiphysis of the 
femur or of the tibia, may simulate tuberculous disease very 
closely. If the tumor is of the periosteal type, it usually forms 
a more localized and irregular swelling than could be accounted 
for by tuberculous disease. Central sarcoma may simulate tuber- 
culous disease also, but the progress of the tumor is more rapid. 
The clinical distinction between the two is that tuberculous dis- 
ease is very amenable to treatment as far as its symptoms are 
concerned, while the progress of sarcoma is but little influenced 
by treatment. It may be stated, however, that the a>ray is the 
only means of early diagnosis, the destruction of the substance 
of the bone about the tumor being much greater than that caused 
by the tuberculous process. 

Hysterical Joint. — Some of the symptoms of disease may be 
simulated by hysterical subjects, but there is always an absence 
of the positive physical signs that invariably accompany a destruc- 
tive disease. These and other affections are described at length 
in the following chapters. 

Treatment. — The treatment of tuberculous disease of the knee 
in childhood is conservative, operative intervention being simply 
incidental to protective treatment. In adult life, on the other 
hand, the radical removal of the disease may be indicated as the 
primary measure. The reasons for this distinction are obvious. 
In childhood the duration of treatment is of no particular impor- 
tance as compared with the final functional result, but in adult 
life the shortening of the period of disability and the definite 
assurance of cure may be of far greater moment than the preser- 
vation of motion. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 417 

In childhood, under favorable conditions, ultimate recovery, with 
fair functional use of the joint, may be anticipated; while a radical 
operation, although it may cure the patient in a shorter time, 
takes away the possibility of a cure with motion. In adult life a 
rigid limb is a strong, useful, if somewhat awkward support, but 
in childhood the removal of portions of the epiphyses and of the 
epiphyseal cartilages entails a progressive inequality in the limbs, 
due to loss of growth, and unless the limb is protected by mechani- 
cal means deformity is the rule, even though the disease has been 
thoroughly removed. Thus the treatment of routine is, in child- 
hood, at least, protection; protection from the traumatism of 
motion, from the shock of impact with the ground, and from the 
pressure of muscular spasm and contraction. 

Mechanical treatment, which is so difficult at the hip, is com- 
paratively easy at the knee, and, as has been stated, the results 
are correspondingly better. At the hip-joint one of the most 
common causes of shortening and deformity is upward displace- 
ment of the femur upon the pelvis, but at the knee, if the limb is 
supported in the attitude of extension, the apposition of the broad 
surfaces of the femur and the tibia prevents displacement, while 
muscular spasm, a symptom whose intensity is in proportion to 
the degree of harmful motion that is permitted, is easily controlled 
by efficient splinting. 

Reduction of Deformity. — The first step in treatment is the 
reduction of deformity that may be present, in order that the 
limb, at the beginning as well as throughout the entire course of 
treatment, may be in absolute normal position; arid as the chief 
function of the leg is to support weight the proper attitude is 
complete extension. Whatever motion the patient retains will 
then be about the point of greatest usefulness. In the cases in 
which an opportunity for reasonably early treatment is offered 
the only deformity is flexion induced by muscular contraction, 
although if it has persisted for some time secondary retraction of 
the muscles may be present. In this class of cases the spasm, 
and consequently the deformity, may be readily overcome by 
placing the joint at rest. 

The Plaster Bandage. — The most efficient splint for this purpose 
in the treatment of ambulatory cases is a close-fitting plaster 
bandage, applied from the groin to the ankle, or better, to 
include the foot, in order to prevent oedema of the unsupported 
part, which is common after the first dressing and until the circu- 
lation of the limb has become adapted to the new conditions. 

27 



418 ORTHOPEDIC SURGERY 

In the application of the bandage the bony prominences of the 
knee and ankle are protected by cotton. A canton-flannel bandage 
is then applied smoothly, and directly upon this the light plaster 
bandage. At the second application, at the end of a week, the 
subsidence of the spasm will permit the straightening of the limb. 
In cases of longer standing several successive applications of the 
bandage may be required, together with manual extension during 
the application; or an anaesthetic may be administered. Under 
anaesthesia the muscular spasm relaxes and deformity, even of some 
standing, may be reduced by traction and by slight leverage, the 
head of the tibia being supported and drawn forward by the 
hands as the deformity is gently reduced. 

Traction. — Deformity may be reduced also by traction with 
the weight and pulley, the leg being supported so that no direct 
leverage is exerted at the seat of the disease (Fig. 273). 




Extension and counterextension in disease of the knee-joint. (Marsh.) 

Forcible Correction by Reverse Leverage. — In the more resistant 
cases, especially if accompanied by subluxation, the following 
method may be employed: The patient is anaesthetized and is 
placed face downward on a table, the feet projecting over its end. 

The body of the patient is then elevated by means of pillows to 
conform to the deformity — that is, the thigh of the affected limb 
is raised sufficiently to allow the tibia to lie evenly upon its ante- 
rior border on the table. The operator with one hand holds 
the head of the tibia firmly against the table and with the other 
massages the contracted tissues of the popliteal region, gradually 
exerting more downward pressure on the thigh, but never to the 
extent to lift the tibia from the table; thus, further subluxation 
is impossible. As the contraction gives way the pillows are 
removed. Usually the deformity may be reduced at one sitting, 
but if it is very resistant complete correction is not attempted. At 
the conclusion of the operation adhesive plaster straps for traction 
and a close-fitting plaster bandage are applied (Fig. 275). 



T TIBER C UL US DISEASE OF THE KNEE-JOINT 4 1 9 

Rest in bed with traction is enforced for a time, and the ordi- 
nary brace is then employed. This is, in the author's experience, 
the most effective and satisfactory method for reducing deformity. 
If the contraction is of long standing preliminary division of the 
flexor tendons may be advisable, but this is not usually necessary. 1 



Tuberculous disease of the knee in an adult, with the form of Billroth splint used 
at the Hospital for Ruptured and Crippled. 

The Billroth Splint.— The Billroth splint, as modified by Still- 
man, is an effective appliance for overcoming resistant deformity. 
A thick pad of felt is placed over the upper surface of the condyles 
of the femur and a thinner pad in the popliteal region over the 
upper border of the tibia. Other points that may be subjected 
to pressure are similarly protected, especially the dorsum of the 
foot and the perineum. A plaster bandage is then applied from 
the groin to the toes, made especially thick and strong in the 
popliteal region. On either side of the knee two curved, slotted 
steel bars attached to expanded tin splints and joined to one another 

1 Whitman, American Journal of the Medical Sciences, May, 1903. 



420 



ORTHOPEDIC SURGERY 



by an adjustable bolt are incorporated in it (Fig. 274). When 
the bandage hardens it is completely divided into two parts by 
a circular cut about the knee, and the bolts in the slots are so 
adjusted as to form a hinged splint, the centre of motion being 
somewhat above and in front of the knee-joint. When the limb 
is slightly extended the position of the hinges has a tendency to 
lift the tibia and to separate it from the femur. This straightening 
opens the cut in the popliteal region, which is held open by a 
wedge of cork. In this manner, by the insertion of larger wedges 
the limb is gradually straightened from day to day until the de- 
formity is overcome, or until a new bandage is required. If the 
pressure on the front of the femur, when the leverage is exerted, 
becomes painful, a part of the padding is removed. 




Illustrating the method of supporting the body and fixing the tibia before straightening 
the limb. The folded sheet indicates the degree of subluxation present. In resistant 
cases of this type an assistant applies the pressure on the thigh. 



In the treatment of older subjects greater force may be em- 
ployed by means of osteoclasts. One of the best machines of this 
type is the Bradford-Goldthwait genuclast (Fig. 276). The more 
violent methods should not be employed during the active stages 
of the disease; and whenever considerable force is required in 
young subjects the possibility of separating the epiphysis of the 
femur, forcing it backward, and thus pressing upon the popliteal 
vessels, should be borne in mind. 

Mechanical Treatment. — The most efficient mechanical appliance 
for the treatment of tuberculous disease at the knee is the Thomas 
knee brace. This consists of two lateral uprights which support 
the limb on either side, terminating below the foot in a crossbar 
shod with leather or rubber, which serves as a stilt, and above in 
a ring that fits the upper extremity of the thigh, and supports 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 421 



the weight^of the body. The brace is made of iron wire from 
three-sixteenths to three-eighths of an inch in thickness. The 
ring is of an irregular ovoid shape, flattened in front, expanded 
behind and wider on the inner than on the outer side (Fig. 277). 
This ring is welded to the uprights at a lateral and antero- 
posterior inclination. The lateral inclination forms an angle with 
the inner bar of 135 degrees (Fig. 279), the anteroposterior 
inclination forms an anterior angle 
of 145 degrees (Fig. 278) with the FlG - 276 

same upright, which is set upon the 
ring at a point slightly in advance of 
its fellow. The objects of the shape 
of the ring and of its inclination are 
these : its anterior part is but slightly 
curved to conform to the surface of 
the groin; its posterior segment is 
expanded to accommodate the thick- 
ness of the buttock; the anteropos- 
terior inclination allows the ring to 
rest comfortably beneath the tuber- 
osity of the ischium. The lateral in- 
clination which follows the line of 
Poupart's ligament is made neces- 
sary by the greater length of the 
outer bar, which in order to assure 
better support and less pressure, rises 
above the level of the trochanter 
major. 

The ring is made somewhat larger 
than the thigh to allow for padding 
with felt. This should be thicker on 
the inner and posterior surface, where 
the weight is borne, than on the ante- 
rior and outer part. The padded ring is then smoothly covered 
with basil leather. As used at the Hospital for Ruptured and 
Crippled, the brace is made from two to three inches longer than 
the leg, to serve as a stilt like the hip splint. To the foot-piece 
two straps are attached on either side to provide for traction on 
the limb and to hold the brace securely in its place. A band of 
leather is drawn between the bars at the upper third and another 
at the lower third of the brace to serve as supports for the thigh 
and calf. Adhesive plasters, reaching from the knee to the ankle, 




The Bradford-Goldthwait genuclast 
for the correction of flexion deformity 
and subluxation at the knee. Counter- 
pressure is applied over the lower ex- 
tremity of the femur. Subluxation is 
prevented during the forcible correc- 
tion by means of the screw and strap 
beneath the head of the tibia, by which 
it is drawn forward. 



422 



ORTHOPEDIC SURGERY 



provided with buckles above the malleoli, having been applied, 
the ring is pushed firmly against the perineum and is held in posi- 
tion by buckling the straps to the traction plasters with as much 
tension as the comfort of the patient will permit. The thigh and 
leg supports should fit the parts perfectly; the knee is then fixed 
in its place by a bandage drawn tightly about it and the lateral 
bars. Ankle and heel straps complete the adjustment (Fig. 281). 




The Thomas knee-splint, showing the 
inner bar B placed farther to the front 
than the outer bar C; A is the lowest 
part of the ring; upon this rests the tuber- 
osity of the ischium. 



The ring of the Thomas knee-splint after 
padding. (Ridlon.) 



In cases in which the joint is sensitive and in which there is 
a tendency to deformity the entire limb is in addition enclosed in 
a light plaster bandage, so-called "skin fitting," applied directly 
upon a flannel bandage. 

If the brace is attached by means of the adhesive plaster straps, 
a certain amount of traction is assured, together with additional 
accuracy of adjustment; and by the traction and by the direct 
pressure on the knee the slighter degrees of deformity may be 
reduced without discomfort. In acute cases preliminary rest in 
bed is advisable, and crutches may be employed in the early stages 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 423 

of ambulatory treatment. But during the greater part of the 
disease the splint serves as a perineal crutch and by the use of 
slight corrective force when the plaster bandages are applied, or 
by traction at times toward one or the other upright, lateral dis- 
tortion of the limb may be corrected during the course of treat- 
ment. This brace may be used in the treatment of very young 
children if it is carefully fitted and if the parts are kept clean and 
dry, and it is an effective brace for all ages, and for all conditions 
of disease. 

Fig. 279 Fig. 280 





Showing the front of the ring of the 
Thomas knee-splint. 



Showing the back of the ring of the 
Thomas knee-splint. (Ridlon.) 



The Caliper Brace. — The traction may be discarded and the 
brace may be held in position by a shoulder band, or it may be 
used as a so-called caliper splint. In this form it was almost 
exclusively employed by Mr. Thomas in his later practice and at 
the present time by Ridlon, 1 the long brace being used simply for 
a bed splint. As a caliper brace the two bars are cut off, turned 
directly inward at a right angle, and are inserted into a steel 
tube, which is passed through the heel of the shoe. The bars are 
made slightly longer than the limb, so that the patient's heel is 
lifted nearly an inch from the inside of the shoe when walking; 
thus, the jar of impact with the ground is prevented. The brace 



American Orthopedic Association, vol. vi. 



424 



ORTHOPEDIC S ITBGEB Y 



Fig. 281 



is fixed in position by a leather band beneath the knee and another 
beneath the calf, and the limb is held extended by pressure pads 
applied to the thigh and leg, as illustrated (Fig. 282). Ridlon 
uses the brace to reduce deformity by direct pressure backward on 
the knee by means of bandages, opiates being given to relieve pain. 
Other braces may be employed, for example, the traction hip 
splint, but as the Thomas brace 
answers every requirement, it seems 
unnecessary to describe others in this 
connection. 

Accessory Treatment.— The acces- 
sories to protective treatment, which, 
of course, includes the proper atten- 
tion to the general condition of the 
r patient, are local applications, injec- 

y tions, and venous stasis. They are 

r«**< classed as accessories because none of 
them is essential to successful treat- 
ment. 

The local application of cautery, ap- 
plied at intervals of a week, or less, 
may add to the comfort of the patient 
and stimulate the reparative pro- 
cesses. The a;-ray appears to act in 
a somewhat similar manner ; it re- 
lieves pain, and in most instances the 
infiltration of the tissues becomes less 
%3 HI marked. 

Ichthyol ointment of a strength of 
about 40 per cent, certainly relieves 
pain and local congestion in certain 
instances. Firm compression by means 
of a flannel bandage and by the ad- 
hesive plaster strapping is of value, 
especially in the infiltrating, "boggy" 
type of disease. The knee is the joint into which injections of 
iodoform emulsion may be made most easily. Such injections are 
more likely to be of service in the synovial than in the osteal type 
of disease. About 10 c.c. of a 10 per cent, emulsion of iodoform 
in sweet oil may be injected through a trocar into the distended 
capsule at intervals of several weeks. It is then distributed by 
gentle massage. It may aid the reparative processes by an irrita- 




The Thomas knee-brace. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 425 



tive stimulation, but it apparently exerts no very direct influence 
on the tuberculous process. 

Bier's treatment by passive congestion may be easily applied 
to the joint. The limb up to the joint is firmly bandaged by 
a flannel bandage. A rubber band is then 
applied immediately above the joint with 
sufficient tension to retard the return of the 
venous blood. The joint then becomes 
swollen and congested. The congestion is 
applied for an hour or more at a time, 
once or twice daily. Passive congestion ap- 
parently increases the stability of the granu- 
lation tissue and its further transformation 
to fibrous tissue. The method should not be 
employed during the acute phases of the 
disease. (See page 262.) 

Treatment during Convalescence. — During 
the active stage of the disease the brace must 
be worn day and night. During the stage of 
recovery it may be removed at night to allow 
for motion at the knee, and later a form of 
walking brace (Fig. 193) that will allow a 
limited motion at the knee may be of service ; 
but this is not an essential in treatment. If 
slight knock-knee remains after recovery, it 
may be overcome by the use of a Thomas 
knock-knee brace, which will also serve as a 
protection to the weak joint. The indica- 
tions of cure have been discussed under hip 
disease. In brief, when sufficient time has 
elapsed to permit of natural cure ; when there 
have been no symptoms of active disease for 
months ; when muscular spasm has disap- 
peared, one may tentatively remove the brace 
in the manner described. But any symptom 
of disease, and particularly increasing limita- 
tion of the range of motion, or a tendency 
toward deformity, indicates the necessity for 
continued protection. If anchylosis is pres- 
ent, supervision and occasional treatment will 
be required during the period of growth in 
order to prevent deformity. 



The caliper splint. E, 
the ring around the upper 
part of the thigh. A, pad 
for backward pressure. B, 
bandage. C, bandage. F, 
leather sling for support at 
the back of the limb. D, a 
strip of bandage fastening 
together the pressure pads 
to prevent slipping and 
consequent loss of pressure. 
(Ridlon and Jones.) 



426 ORTHOPEDIC SURGERY 

Extra-articular Disease and Operative Intervention. — In certain 
cases, especially in young children, the disease about the epi- 
physeal cartilage of the femur or of the tibia may find its way to 
the exterior of the bone before it invades the joint. This fortu- 
nate course is indicated by local sensitiveness and swelling over 
one of the condyles of the femur or about the head of the tibia. 
In such instances the thorough removal of the disease is indi- 
cated, or if a Roentgen picture shows that the disease is accessible 
even though it is not immediately below the surface, an explora- 
tory operation may be advisable. Ah incision is made, usually 
over the internal condyle of the femur. The periosteum is raised 
and a portion of the cortex is removed in order to expose the 
spongy bone on either side of the epiphyseal cartilage. 

In many instances an area of softening will be found. This 
must be thoroughly removed. The cavity may be treated with 
pure carbolic acid or the cautery, or filled with iodoform mass 
and the wound is then closed. In favorable cases prompt opera- 
tive intervention may cut short the course of the disease. 

Abscess. — Abscess is present as a complication in about one- 
third of the cases that have received efficient protection, and in a 
larger percentage of those in which treatment has been neglected. 

It was present in 51 per cent, of Koenig's cases 1 and in 47 per 
cent, of three hundred final results reported by Gibney. 2 At the 
knee, as at other joints, the infected abscess is the most dangerous 
complication of the disease, as is illustrated by Koenig's statistics : 

Death-rate in cases without abscess 25 per cent. 

with abscess 46 " 

Although in many instances abscess indicates an extensive and 
destructive disease of the bone, yet the exhausting suppuration 
that is an indirect cause of death is suppuration from infected 
areas in the thigh and leg, which may have little direct relation 
to the extent of the original disease. It should be the aim in 
treatment to prevent this burrowing of fluid after the capsule has 
been perforated, and to prevent overdistention of the capsule even, 
in order to lessen the macerating effect of the tuberculous fluid 
upon the cartilages. When the fluid within the joint is of con- 
siderable amount, and when it is increasing in quantity, it may 
be removed by aspiration, or a better procedure is to incise the 
capsule. This will permit thorough removal of its fluid and 
solid contents, after which the opening may be closed with sutures. 

1 Loc. cit. - American Journal of the Medical Sciences, October, 1893. 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 427 

Tuberculous abscess which has perforated the capsule may be 
treated in the same manner, or it may be drained subsequently, 
according to the indications. Unless the abscess is infected 
careful bandaging of the thigh and leg should prevent burrowing. 

Synovial Tuberculosis. — In the forms of synovial tuberculosis 
that resemble chronic synovitis the fluid, if the quantity is large, 
may be evacuated by an incision in the capsule which will allow 
for exploration and for removal of the fibrinous masses that are 
often present. Afterward the interior of the joint may be treated 
with an application of a strong solution of chloride of zinc or pure 
carbolic acid. This sets up an active reaction which causes adhe- 
sions within the capsule, and exerts a favorable influence on the 
course of the disease. A protective brace should be worn to 
guard the joint from sudden twists and strains and to limit the 
range of motion within the painless arc (Fig. 193). The adhesive 
plaster strapping may be employed in cases of this class with great 
advantage. It is in this type of disease that pass've congestion is 
most effective. The same is true of the injection of iodoform 
emulsion. Theoretically, its use should modify the infectious 
quality of the tuberculous fluid and lessen the danger of infection 
with pyogenic germs, and on this ground, rather than because it 
actually shortens the course of the disease, it may be recom- 
mended. 

Arthrectomy. — When, as in exceptional cases, the disease is pro- 
gressive and shows no tendency toward recovery, and particu- 
larly if an infected abscess communicating with the joint makes 
efficient drainage difficult, the operation of arthrectomy may be 
indicated. 

An Esmarch bandage having been applied, the joint is thor- 
oughly exposed by a curved anterior incision passing above or 
below or through the patella, and all the diseased tissue is re- 
moved; that in the soft parts is cut away, and foci in the bone 
are excavated with the chisel and scoop. If infection be present 
the joint may be packed with gauze, the leg being fixed in the 
position of flexion; but in other instances the wound is closed 
with or without drainage as may seem advisable. In a large 
proportion of cases primary healing may be obtained. By the pro- 
cedure one may hope to cure the disease, but in all but exceptional 
cases the functional result will be anchylosis. The operation has 
the advantage over complete excision in that less bone is removed, 
and that the epiphyses, in part, at least, remain; thus, the imme- 
diate as well as the ultimate shortening is less than after excision. 



428 ORTHOPEDIC SURGERY 

Results of Artheectomy. — The direct death-rate of the 
operation is small. In 150 cases reported by Koenig but 3 deaths 
were attributable to the operation itself. The final results in 114 
of these cases, in which the operation was performed in childhood, 
were as follows: 

Patients cured and living 90 

Cured of the local disease, but not living at the time 

of the investigation 10 

Practically cured, insignificant fistulae remaining . 2 

102 = 89.5 per ct. 

Living, not cured 5 

Deaths before the cure of the local disease ... 7 

12 = 10.5 per ct. 

Thus in 89 per cent, of the cases the operation was successful 
as far as the cure of the local disease was concerned. In 75 per 
cent, of the successful cases immediate cure was attained; in 25 
per cent, fistulas persisted for a longer or shorter time. In 10 
cases some motion was retained, but in the others anchylosis fol- 
lowed the operation. In about 70 per cent, of the cases the limb 
was practically straight; in 30 per cent, it was distorted. This 
shows the necessity of continued supervision and in many in- 
stances of protective treatment during the growing period in all 
cases in which anchylosis is present from whatever cause. 

In forty-eight cases in which the operation had been performed 
before the tenth year, and in which the limbs were straight, the 
influence of the operation on the growth was investigated. 

Years elapsed Average shortening 

Number of cases. since operation. in cm. 

6 2 1 

5 3 1.6 

4 4 1 

3 5 2 

19 6-7 2 

11 8-13 2.5 

These measurements indicate that the shortening is not likely to 
be very great as a result of the operation, certainly very much less 
than after complete or even partial excision performed at the 
same age. 

Excision. — Excision of the joint in childhood has been practi- 
cally abandoned, because of the great shortening that follows 
complete removal of the epiphyses, and because so-called partial 
excision — that is, the removal of the thin sections of bone from the 
surfaces of the femur and tibia, leaving the cartilages — is usually 
an unnecessary operation, in the sense that disease that might 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 429 



be cured by this procedure might have been cured by conservative 
methods. 

Early excision in adult cases is often indicated because it will 
assure a cure of the disease in a short time, whereas mechanical 
treatment will at best require years of disability with no certain 
prospect of absolute cure at the end of the period. If, therefore, 
the disease has progressed sufficiently to indicate that the natural 
cure would result in anchylosis, or if the time required for natural 
cure is of importance to the 

patient, early excision may be FlG - 283 

advised in the case of the adult 
or adolescent whose growth is 
nearly completed. 

The operation is performed 
under the Esmarch bandage, 
and the joint is exposed by the 
anterior incision, as in the oper- 
ation of arthrectomy. All the 
diseased tissues are cut away 
and sections of the bones, par- 
allel to the articular surfaces, 
are removed sufficient in depth 
to include all the diseased area. 
The sections should allow the 
bones to be brought into close 
apposition and they should be 
held by strong sutures of catgut. 
The vessels having been ligated, 
the wound may be closed with 
or without drainage, as may be 
indicated by the character of the 
disease, a plaster-of-Paris dress- 
ing is applied, and the limb is 

elevated. Mechanical support is of service in the after-treatment 
in lessening the discomfort and hastening the cure. 

Results of Excision. — In Koenig's statistics of 300 excisions, 
6 deaths were due directly to the operation, and 23 others occurred 
during the course of the after-treatment — a total of 29 (9.6 per 
cent.). 

In 23 instances amputation was afterward performed because 
of failure of the operation. The good results are classed by 
Koenig as 75 per cent., the bad as 25 per cent. In 193 cases 




Deformity and shortening resulting from ex- 
cision of the knee in childhood. 



430 ORTHOPEDIC SURGERY 

the position of the limb in after years was investigated. It was 
straight in 175, distorted in 18, all but 1 of this latter group being 
in children. Of 400 resections of the knee in Bruns' clinic final 
results were ascertained in 379 cases. The early results were as 

follows: 

Discharged, well 343 

with fistulas 29 

Amputated 17 

Dead ' . 17 

Not cured 4 

Final results: 

Well 280 

With fistulas 3 . , 

Dead, but cured of local di.=ea«e . 45 

Dead, not cured 3 

Living, not cured 10 

Dead - " . " 6 y : 

Died in clinic 7 

Amputated 23 

Curvature of the limb: 

Straight 27.1 per cent. 

Moderately flexed 28.0 

Mechanically flexed 44.9 

Amputation. — This operation is indicated as a life-saving meas- 
ure. When the disease is so extensive as to require complete 
removal of the epiphyses in early childhood, amputation is 
the preferable operation, as the limb, aside from requiring con- 
stant protection to prevent deformity, will be so short as to be of 
little practical use. 

Operations for the Relief of Final Deformity. — In the majority 
of the cases deformity can be rectified by one of the methods 
already described. If, however, there is bony anchylosis in an 
attitude of marked flexion the limb may be straightened by the 
removal of a sufficient wedge of bone from the joint. The defor- 
mity may be remedied almost equally well by linear osteotomy 
of the femur just above the joint, supplemented if the deformity 
is extreme by a secondary osteotomy of the tibia. If flexion 
deformity is of long standing the correction should not be com- 
pleted at the first operation out preferably at several sittings to 
permit the adaptation of the soft parts and the bloodvessels to the 
new attitude. Simple osteotomy is to.be preferred in young sub- 
jects, as no bone is removed. 

Genu valgum may be corrected by a similar operation. (See 
Osteotomy for Knock-knee.) 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 431 

In certain selected cases the joint may be opened for the pur- 
pose of separating the bones and interposing flaps of fibro- 
muscular tissue. Although the prospect of restoring useful motion 
is slight, it will at least serve to correct deformity. See Anchylosis. 

Prognosis. — -The most important statistical evidence on the 
course and the outcome of tuberculous disease of the knee-joint 
in childhood has been presented by Gibney. The statistics com- 
pleted in 1892 were the result of an investigation of 499 cases 
treated during a period of twenty years, 1868-1887. In but 
300 of these could definite information be obtained. 1 

Eighty-seven per cent, of the cases were in children, and 51 
per cent, of the patients were less than five years of age at the 
inception of the disease. 

The cases were divided into three classes, according to the 
treatment that had been followed: 

1. The expectant treatment. In this class no apparatus was 
employed, or, if employed, it had been efficient. 

2. The fixation treatment. In this class the joint had been more 
or less efficiently splinted, but not protected from impact with 
the ground. 

3. The protective treatment. In this class the joint had been 
splinted and protected from jar, and the mechanical treatment 
had been efficient. 

The results were classified as follows: 





Total. 


Excisions. 


Amputations. 


Deaths. 


Under 
treatment. 


Cured. 


Expectant . 
Fixation . 
Protection . 


71 
190 
39 


5 

9 



:-! 
1 



35 


9 
31 
Jl 


51 

'it 




300 


u 


4 


40 


51 


191 



Mortality.— The total deaths in the 300 cases were 40 (13.3 
per cent.); 26 of these were from causes directly or indirectly 
connected with the disease (8.6 per cent.), viz.: 

Operative shock 1 

Prolonged suppuration 16 

Tuberculous meningitis 6 

Phthisis 3 

26 
Intercurrent diseases 14 

40 

1 American Journal of the Medical Sciences. October, 1893. 



432 



OR THOPEDIC SURGERY 



Function. — The functional results as regards motion in the 
cases in which conservative treatment had been continued to the 
end, including the cases still under observation, 242 of 300, were 
as follows : 





Total. 


Motion retained. 


Anchylosed. 


Expectant 

Fixation . 

Protection 


60 
145 
37 


44 or 73 per cent. 
113 "77 " 
34 "95 " 


16 
32 
3 




242 


191 or 79 per cent. 


51 



Of the 191 patients who retained a movable joint, 74 had 
had abscesses, 3 or more cicatrices being present in 39. 

As to the range of motion, in 74 it was from 45 degrees to normal 
and in 41 more than 90 degrees; thus 30 per cent, of the patients 
retained a fair range of motion. 

Deformity. — In 51 cases anchylosis was present; in 16 of these 
the limb was practically straight, in 35 it was flexed more than 
30 degrees (69 per cent.). 

These statistics again illustrate the great tendency toward 
deformity, when during the growing period there is anchylosis at 
the knee from whatever cause. 

In the 191 cases in which motion was retained the limb was 
practically straight in 125 (65 per cent.). In 49 others the flexion 
was less than 25 degrees, and in but 16 could the deformity be 
classed as bad (8 per cent.). 

In 10 cases only did relapse occur after apparent cure. 

In but 16 of the 449 cases was there involvement of other joints 
while the patients were under observation (3.2 per cent.). Iu 
8 of these the spine was involved, in 2 the hip, and in 6, other 
joints. 

The influence of age upon the death-rate and the ultimate 
causes of death are illustrated by Koenig's statistics, the death- 
rate being much higher, at least in the cases in early childhood, 
than in this country. 

According to Koenig's statistics, the death-rate, direct and 
indirect, from disease of the knee-joint, was as follows: 



323 children (1 to 15 years of age), deaths ... 65 = 20 per cent. 

225 patients (16 " 30 " " ), " .... 61 = 24 " 

68 " (31 " 40 " " ), "... 30 = 44 " 

74 " more than 40 years of age " ... 45 = 60 " 



TUBERCULOUS DISEASE OF THE KNEE-JOINT 433 

Causes of Death. 

Deaths from causes not connected with the disease . . 14 = 2.0 per cent. 

" following operations 18 = 2.5 " 

" caused by tuberculosis, 141 = 22. 5 per cent, of all cases and 80 
per cent, of all the deaths. 

Tuberculosis of the knee 1 

" " lungs 94 

General tuberculosis 30 

Tuberculous meningitis 7 

Acute miliary tuberculosis 3 

Tuberculosis of other parts 6 

141 

It may be noted that 16 of the 40 deaths in Gibney's cases 
were due to prolonged suppuration, and that of 51 cases still 
under observation 26 had been treated for ten years or longer, 
and were still uncured. This indicates that in a larger propor- 
tion of the cases conservative methods should have been supple- 
mented by more radical treatment. Still, taken as a whole, the 
results, although the mechanical treatment was, in many instances, 
far from efficient, are much better than any others that have been 
presented. 

General Conclusions. — On this evidence the following con- 
clusions seem to be justified: The death-rate in childhood from 
all causes should be less than 10 per cent. The duration of 
treatment is from two to five years. Recovery with a useful 
range of motion, when the diagnosis has been made at an early 
stage and when efficient mechanical treatment has been employed, 
may be predicted in 50 per cent, of the cases. 

Deformity can always be prevented by treatment and by super- 
vision. Under favorable conditions radical operations are not 
often indicated, but when indicated they should not be delayed 
too long. Amputation of the limb should prevent death from 
prolonged suppuration. In a certain proportion of cases the 
disease may be cut short by early exploratory operations for the 
removal of foci of disease in the bone before the joint has become 
involved. 

Although the benefits of protective treatment are as evident in 
disease of the adult as in childhood, yet early operation is often 
indicated in this class, because of the necessity for shortening the 
period of disability, and because excision assures a straight and 
useful limb. 



28 



CHAPTER X. 

NON-TUBERCULOUS AFFECTIONS AND DEFORMITIES OF THE 
KNEE-JOINT. 

Strains and Injuries of the Knee in Childhood. 

Injury of the knee in childhood may cause local discomfort 
and persistent flexion of the leg, even when but little synovial 
effusion is present. In this class of cases the application of a 
plaster bandage, under sufficient traction to overcome the deform- 
ity, is of service in placing the part at rest and preventing further 
injury. The importance of treating promptly slight injuries of 
the joints in childhood, especially in the class of patients predis- 
posed to tuberculous infection, has been mentioned already in the 
consideration of hip disease. 

Muscular "cramp," a form of tetanic contraction, induced 
possibly by injury, which fixes the limb in a flexed or extended 
position, is sometimes seen in children of a susceptible or nervous 
temperament. The treatment is similar to that of strains. 

Acute Synovitis. 

The knee from its size and position is especially liable to injury, 
which if of any severity is usually followed by effusion of fluid 
within the joint (synovitis). Its symptoms are discomfort, swelling, 
local heat, and limitation of motion. According to Tenney 1 the 
patella floats when 30 c.c. of fluid is contained in the joint, the 
extreme of normal capacity being 200 c.c. 

Injury and its attendant synovitis may be treated, immedi- 
ately, by splints, by elevation of the limb, by the application of 
ice-bags and the like; but after the acute symptoms have sub- 
sided the absorption of the effused fluid is aided by functional 
use of the limb, if the joint is properly protected. One of the 
most efficient methods of treatment is that by means of the ad- 
hesive plaster strapping advocated by Cottrell and Gibney. The 
entire surface of the knee, except a narrow space in the popliteal 

1 Annals of Surgery, July, 1904. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 435 

region, is firmly strapped with overlapping layers of adhesive 
plaster, extending from the upper third of the leg to the middle 
third of the thigh; and over this a flannel bandage is applied; 
or if the leg is swollen, the entire limb should be firmly bandaged 
with elastic stockinette bandage, from the toes to the upper third 
of the thigh in addition (Fig. 291). The adhesive plaster serves 
as a support which allows a certain degree of motion, sufficient to 
stimulate the circulation, and thus to hasten the restoration of 
the normal condition. If greater compression is desired, the 
entire joint may be covered with the adhesive plaster as suggested 
by Hoffmann. 1 A pad of cotton is placed in the popliteal space, 
a close-fitting stocking leg is drawn over the knee, and about 
this circular bands of plaster are drawn as tightly as the comfort 
of the patient will permit. The adhesive plaster strapping is 
renewed from time to time, as the swelling diminishes, and its 
use is continued until the symptoms have entirely disappeared. 
Chronic traumatic synovitis may be treated in a similar manner, 
although if the effusion is persistent the fluid may be removed 
by aspiration. If the ligaments are lax, a supporting brace may 
be required for a time (Fig. 193). Massage and exercises and 
static electricity are of service in the stage of recovery to restore 
the strength and activity of the supporting muscles. 

Chronic and Recurrent Synovitis. 

Chronic synovitis is of far greater interest from the orthopedic 
standpoint than the acute form because it is usually symptomatic 
of some general pathological condition or change within the joint. 

Bennet 2 has analyzed 750 cases, the apparent causes of the 
effusion being as follows : 

Local. 

1. Internal derangement of the joint" 428 

2. Loose bodies in the joint 24 

3. Genu valgum 4 

General. 

1. Osteoarthritis 107 

2. Rheumatism and gout . 30 

3 Syphilis 42 

4. Gonorrhoea 28 

5. Malaria 18 

6. Haemophilia 3 

1 New York Medical Journal, January 27, 1900. 

2 Lancet, January 7, 1905. 



436 ORTHOPEDIC SURGERY 

In 56 cases no cause could be assigned and 13 were instances 
of what he calls "quiet effusion." 

Internal Derangement of the Knee-joint. (Hey.) 

Internal derangement signifies sudden interference with the 
function of the joint which may be due to (a) loose bodies in the 
joint; (6) displacement or fracture of a semilunar cartilage; (c) 
other injury. 

Loose Bodies in the Knee-Joint. 1 — Loose bodies in the knee- 
joint may be composed of portions of fibrin, fragments of synovial 
membrane, or bits of cartilage or bone, and the like. In certain 
forms of synovial tuberculosis and osteoarthritis these loose bodies 
may be present in large numbers. From the therapeutic stand- 
point, however, the important cases are those in which the joint is 
otherwise normal. In this class the foreign body is sometimes 
detected by the patient as a smooth, movable object on one or the 
other side of the patella; but in many instances the first sign of 
its presence is interference with the function of the joint. After 
a sudden movement or when the knee has been flexed, as in the 
kneeling position, or without appreciable cause, severe pain in 
the knee is felt and the joint may be fixed in the position of flexion. 
By massage, manipulation, or spontaneously the foreign body 
is dislodged from between the surfaces of the bone and movement 
becomes free and painless, but discomfort remains for a time 
and in most instances synovial effusion follows. These symp- 
toms recur at intervals, and the disappearance of the movable 
body from its accustomed place at such times may demonstrate 
its relation to the disability. 

Displacement of a Semilunar Cartilage. — Displacement of a 
semilunar cartilage is usually of traumatic origin. The tinnreal 
cartilage is most often affected. The displacement is usually 
caused by an outward twist of the tibia upon the femur. The 
patient's limb is fixed in the attitude of flexion, and in certain 
instances an irregularity may be detected at the inner and upper 
border of the tibia. 

To replace the cartilage the leg should be flexed, then suddenly 
extended and rotated inward. In some instances an anaesthetic 
may be required. The displacement is followed by discomfort 

1 According to Immelmann (Zeits f. artz. Fortbildung, 1904 No. 5.), in 30 per cent, of 
normal individuals a sesamoid bone may be found beneath the external head of the 
gastrocnemius muscle that might on an x-ray examination be mistaken for a loose body 
within the joint. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 437 

and synovial effusion. The accident having once occurred, is 
likely to recur; the patient recognizing the character of the move- 
ments that are likely to cause the displacement, also the proper 
manipulation for its replacement. 

Injury. — In other instances somewhat similar symptoms may 
follow injury at the knee, pinching of the synovial membrane, 
bruising or fracture of the cartilage, or a strain of one of the 
ligaments within the joint, being assigned as causes. In cases of 
this character, in which symptoms recur from time to time, the 
joint becomes weak and insecure, partly because of the repeated 
synovial effusion and partly because of the muscular relaxation. 

Treatment. — If the patient is seen immediately after the dis- 
placement or injury the limb should be fixed in a plaster bandage 
for four weeks or more to allow for reattachment of the displaced 
part. Afterward the joint may be protected by the adhesive plaster 
strapping, and when the effusion has been absorbed massage and 
exercises for strengthening the muscles should be employed. 

In the more chronic cases in which the ligaments are lax, a 
brace which will permit anteroposterior motion, but prevent 
lateral mobility, may be required. The Campbell brace (Fig. 
193), used by Shaffer, is a light and effective support that inter- 
feres little, if at all, with the use of the limb. 

If the diagnosis of displaced or fractured cartilage can be 
verified, and if it is the cause of persistent disability, it should 
be removed. And the same may be said of isolated foreign 
bodies which are known to be the cause of the symptoms. 

Under the Esmarch bandage the joint is opened by an incision 
about three inches in length on the anterolateral and internal 
aspect of the joint. After the capsule is opened the leg is flexed 
to bring .the cartilage into view. If loose it is then separated 
from its attachments with a tenotomy knife and is removed. The 
capsule is then united with a fine catgut, the wound is closed, and 
a plaster bandage is applied. At the end of a week or more the 
patient may walk about. At the end of a month the adhesive 
plaster strapping may replace the bandage or preferably in cases 
of long standing the Campbell brace may be applied. Perfect 
functional recovery is the rule. 

Hyperplasia. 

Hyperplasia of Fatty Tissue within the Joint. — The largest of the 
pads of fibrofatty tissue within the knee-joint is of a somewhat 



438 OB TH OPED 10 SUBGEBY 

triangular form, its base lying in the interval between the femur and 
the tibiae, its apex projecting upward, held between the femoral 
condyles by the ligamentum patellae and the ligamentum mucosum. 
This may become enlarged and sensitive to motion and pressure. 
In such cases a somewhat sensitive swelling appears on either 
side of the patella and its ligament. The patient suffers from 
discomfort particularly on changing from a position of rest to 
activity and from creaking sensations or even interference with 
motion. At times synovitis may be present. If the symptoms 
are not relieved by rest, strapping or other conservative treatment, 
the removal of the hypertrophied tissue is indicated. Sensitive 
tumors of a similar nature may appear in other parts of the joint 
and folds or masses of hypertrophied synovial membrane, the 
effect usually of repeated inflammation may induce similar symp- 
toms. In such cases exploration of the joint, for the purpose of 
ascertaining the cause of the symptoms or for removal of the 
obstructing parts, is indicated. 

Incidental Synovitis. 

Strains of the knee-joint slight in degree may be induced by 
genu valgum, by slipping patella and the like, and discomfort is 
not infrequently an accompaniment of the weak foot. It may 
be stated also that simple over- weight or strain, as for example, 
laborious work in fat subjects, may induce discomfort, creaking 
sensations, and slight effusion in the joint. In fact, over-weight 
is the most constant of all the aggravating causes of weakness in 
the knees of the character indicated. Reduction of weight by 
proper diet is therefore an important indication for treatment. 

"Quiet Effusion." 

Painless synovitis at the knee or other joints is sometimes 
observed in young girls. It has apparently some connection 
with menstrual irregularites. Recurrent effusion of a similar 
character in one or both knees is occasionally seen in older subjects. 
Without appreciable cause and at fairly regular intervals the 
joint is filled with fluid, the principal discomfort being the tension. 
The swelling persists for several days and disappears. In the 
intervals the joint appears to be normal except for a certain laxity 
of the ligaments. 

Attention is again called to the fact that chronic svnovitis con- 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 439 

fined to a single joint which shows no tendency to improvement 
is often tuberculous in character. 1 

One case has come under my observation and eight others are 
reported, in but one of which was there general dissemination of 
the disease. 

Other forms of synovitis or joint disease dependent upon 
general constitutional causes or upon direct infection have been 
considered in Chapter VI. 

Prepatellar Bursitis. 

Synonym. — Housemaid's knee. 

A chronic enlargement of the bursa lying over the patella and 
its ligament is common among those who have to kneel much 
of the time; hence the popular name. Occasionally cases of acute 
bursitis, in which there is considerable effusion into the sac, are 
seen, and these are sometimes mistaken for synovitis of the knee. 

Treatment. — In acute cases strapping the front of the knee 
with strips of adhesive plaster which will limit motion and 
provide compression is an effective treatment. If the effusion is 
considerable it may be relieved by aspiration or incision. In 
chronic cases cure can be attained only by the removal of the 
thickened sac. 

Pretibial Bursitis. 

Beneath the ligamentum patella?, occupying the space between 
the tendon and the periosteum of the tibia, is the deep pretibial 
bursa. It is, according to the investigations of Lovett, 2 as wide 
or somewhat wider than the tendon; its upper border is on a 
level with the joint, its lower border reaches to the tubercle of 
the tibia, and, being slightly longer on the outer than on the 
inner border, it is somewhat triangular in shape. It does not 
communicate with the knee-joint. 

Enlargement of this bursa is, as a rule, the result of injury, 
but, as bursitis elsewhere, it may be a complication of infectious 
diseases, rheumatism and the like. 

Symptoms.— The symptoms are stiffness at the knee and pain 
on sudden movement, especially when strain is exerted on the 
tendon by complete flexion or extension of the leg as in active use. 

1 In rare instances primary sarcoma of the capsule may cause chronic synovitis. The 
principal diagnostic points are the local or general thickening of the capsule and the blood- 
stained fluid obtained on aspiration. The course of the disease is very chronic and 
its malignancy is slight. Thorough removal of the capsule with or without excision would 
seem to be indicated. 

2 Boston City Hospital Reports, 1897, 8th series. 



440 ORTHOPEDIC SURGERY 

The tubercle of the tibia seems enlarged and is sensitive to pres- 
sure, and a swelling on either side of the ligament is usually ^vident. 
Treatment. — The affection, if at all acute, may be treated by 
relieving the strain and pressure on the tendon, by fixation of 
the limb for a time in a plaster bandage or other form of splint. 
Later the adhesive plaster strapping will provide sufficient fixa- 
tion and pressure. The absorption of the fluid may be hastened 
by the application of the cautery. If the swelling is persistent, 
the fluid may be removed by aspiration or incision or removal 
of the sac. 

Enlargement of the Superficial Pretibial Bursa. 

A small bursa, lying upon the. insertion of the ligamentum 
patellae, may become enlarged, causing an apparent hypertrophy 
of the tubercle of the tibia. It may be treated by strapping with 
adhesive plaster, and the prominent tubercle should be protected 
by some form of bunion plaster. 

Injury of the Tibial Tubercle. 

Osgood 1 has called attention to the fact that symptoms resem- 
bling those described may be caused by partial separation of the 
tubercle of the tibia. The treatment is primarily rest in the 
extended attitude. 

Bursae and Cysts in the Popliteal Region. 

Simple inflammation of the bursa lying between the inner head 
of the gastrocnemius and the semimembranosus muscle may cause 
a fluctuating swelling on the inner side of the popliteal region. 
It may be treated by compression, by incision, or by complete 
removal as may seem advisable. Cysts in the popliteal region 
usually communicate with the knee-joint and are complications 
of rheumatic or tuberculous disease. In such cases they are of 
interest principally from the diagnostic standpoint. 

Acquired Genu Recurvatum. 

Synonym.— Back knee. 

Genu recurvatum, as the name implies, is a deformity in which 
the knee is habitually overextended. 

1 Boston Medical and Surgical Journal, January 29, 1903. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 441 

Etiology. — Acquired genu recurvatum may be a simple local 
deformity, or it may be secondary to weakness or distortion of 
other parts. Local or primary genu recurvatum may be an effect 
of rhachitis, or of disease or injury of the femur or tibia. In 
this form the femur may be curved sharply forward above the 
joint, or the upper extremity of the tibia may be bent backward 
at the epiphyseal junction, and flexion may be limited by the 
obliquity of the articulating surfaces. 

More often the deformity is secondary. It may be, for example, 
an effect of equinus, either congenital or acquired, in which 
the knee is strained by the effort of the patient to place the heel 
upon the ground. It may be caused by the use of a brace in 
the treatment of hip disease, if the knee-joint is not properly 
supported, and it is often seen also as a result of disease at this 
joint, for which no apparatus has been employed. It even 
appears in some instances on the sound side, apparently as a form 
of compensation for the shorter limb (Fig. 206). It is one of the 
comparatively infrequent complications of disease at the knee- 
joint, for which the leg has been supported by the brace in an 
extended or overextended position, or in which the growth at the 
epiphyseal cartilages of the femur or tibia has been irregular. 
In rare instances it is the direct result of traumatism, as when 
the limb has been suddenly forced into an overextended position, 
and the posterior ligaments, and possibly the crucial ligaments, 
also, have been ruptured or weakened. It is most often, however, 
an accompaniment of paralysis of the posterior thigh muscles or 
of the gastrocnemius muscle, or both. A slight degree of over- 
extension at the knees is not uncommon in children who have 
the so-called loose joints. 

In many cases genu recurvatum is combined with a varying 
degree of knock-knee, and there is often an abnormal mobility at 
the joint that allows a certain amount of posterior displacement 
of the tibia. In extreme cases of this class there may be well- 
marked subluxation. 

Symptoms. — The symptoms, aside from the deformity, are 
weakness and insecurity caused by the hyperextension when 
weight is borne. If the deformity is extreme, the strain upon 
the weakened parts usually causes discomfort. Flexion is ren- 
dered difficult because of the abnormal relation of the joint sur- 
faces and by the accommodative changes in the ligaments and 
muscles, so that in extreme cases the patient swings the leg along 
in the extended or overextended position. 



442 



ORTHOPEDIC SURGERY 



Treatment. — If the recurvation is caused by deformity of the 
bones, the normal relations may be restored by osteotomy of the 
tibia or femur, as may be indicated. Deformity secondary to dis- 
tortions elsewhere may be treated by remedying the primary cause. 

Traumatic genu recurvatum may be treated by fixation in the 
flexed position until the repair is complete, afterward by massage 
and support if necessary. The ordinary form of overextended 
knee, combined with lateral mobility, must be supported by a 
brace which permits only anteroposterior motion to the normal 
limit or slightly less. Whenever possible massage and exercises 
should be employed. 

Congenital Genu Recurvatum. 

Synonym. — Anterior displacement of the tibia. 

The most common of the congenital deformities at the knee is 
the so-called genu recurvatum, in which the knee is bent some- 
what backward; or, in other words, the leg is hyperextended on 




Congenital genu recurvatum. (Hoffa.) 

the thigh. The condition is often spoken of as an anterior dis- 
location, but there is no actual displacement, except in the extreme 
cases in which the tibia may be turned directly forward on the 
femur, even to a right angle or less. In the ordinary cases the 
range of extension is merely exaggerated, while flexion is limited 
or checked, principally by adaptive shortening of the quadriceps 
extensor muscle (Fig. 284). In "some cases there may be changes 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 443 

in the direction of the articulating surfaces in adaptation to the 
deformity of the femur and tibia. 1 

The appearance in well-marked genu recurvatum is very 
peculiar; it is as if the patient's leg were reversed, for the popliteal 
depression has become a prominence and the range of overexten- 
sion seems to represent normal flexion. In such cases the leg 
may be brought to the straight line, but greater flexion is resisted 
by the retracted tissues, and when the pressure of the hand is 
removed the leg is drawn back to the deformed position by the 
contraction of the quadriceps extensor muscle. 

Other Deformities and Malformations. — Genu recurvatum is not 
infrequently accompanied by varus or valgus deformity at the 
knee, more often by the latter, and by laxity of the ligaments. 
In many instances the patella is absent or is rudimentary, and not 
infrequently the deformity is accompanied by malformations or 
defective development of other parts. 

Seventy-eight cases were collected by Potel. 2 In 37 instances 
the deformity was limited to one side; in the others both limbs 
were affected. In 50 cases the condition of the patella was noted; 
in 26 of these it was absent or rudimentary. Twenty of the cases 
were accompanied by talipes. 

Etiology. — The deformity in cases of simple recurvatum may 
be explained by an abnormal and fixed position in utero, and in 
cases seen soon after birth the mechanism is clearly shown by the 
habitual attitude. The thighs are sharply flexed on the body; 
the dorsal surfaces of the hyperextended knees are in relation 
to the abdomen, while the feet may be brought into contact with 
the face or trunk, according to the degree of deformity. The 
retarded development of the quadriceps extensor muscle explains 
the rudimentary patella which is often an accompaniment of the 
deformity. 

Treatment. — The treatment of the hyperextended knee is very 
simple. It consists in massage of the atrophied and contracted 
muscles, combined with more or less forcible manipulation in the 
direction of flexion. If, as is often the case, the leg seems to be 
drawn forward by spasmodic muscular action, the methodical 
massage should be combined with the use of a simple posterior 
splint. 

In the more extreme cases manual force may be applied under 
anaesthesia, and the deformity may be overcome at one or several 

1 Delanglade, Bevue d'Orthop<5die, May, 1903. 

- Etude sur les Malformations Conge"nitale du Genou. Lille, 1897, Imp. L. Daniel. 



444 ORTHOPEDIC SURGERY 

sittings, according to the resistance of the contracted parts. The 
limb is then fixed in a flexed position until the tendency to recur- 
rence has been overcome. When the child begins to walk a light 
lateral brace may be necessary to ensure perfect functional use of 
the joint, as in many instances laxity of ligaments and muscular 
weakness may persist for a long time. 

Rudimentary or Absent Patella. 

As has been stated, a rudimentary patella is a frequent com- 
plication of genu recurvatum or of any congenital defect or de- 
formity of the knee or limb that involves imperfect development 
of the quadriceps extensor muscle. In many cases of this type 
it is impossible to distinguish the patella during the early months 
of infancy, but later a minute patella appears that slowly in- 
creases to an approximately normal size. 

Absence of patella under the same conditions is less frequent, 
although Potel collected one hundred cases from literature. 

Treatment. — The treatment of rudimentary patella is included 
in the massage and stimulation of the atrophied or rudimentary 
muscle with which it is usually associated, and the support that 
the weak or deformed knee may require. 

Congenital and Acquired Displacement of the Patella. 

The patella may be displaced upward as a result of extreme 
genu recurvatum, and in rare instances it may be displaced inward 
or downward, but far more often the displacement is outward. 
Fifty cases of this form are recorded, in most of which it was a 
complication of congenital genu valgum. 

Acquired complete displacement in which the patella lies on 
the outer aspect of the external condyle is most often an accom- 
paniment of extreme genu valgum. The first step in treatment 
must be to remedy the distortion of the limb, but if the deformity 
is of long duration the tissues on the anterior aspect will have 
become so shortened that flexion will be much limited. 

Slipping Patella. 

This term is applied to an abnormal laxity of the supporting 
tissues that allows occasional displacement of the patella upon 
or to the outer side of the external condyle. 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 445 

Etiology. — This disability is more common among females 
than males, and is more often unilateral than bilateral. The 
abnormal mobility may be an inherited peculiarity; it may be 
due to weakness of the quadriceps extensor muscle, or to imper- 
fect development of the patella or of the external condyle; or the 
original displacement may have been due to injury. In many 
instances, however, the predisposing cause is genu valgum, as a 
consequence of which the patella is carried toward the external 
condyle. Slight occasional displacement sufficient to cause 
discomfort is a not uncommon accompaniment of weak feet, 
which indicates as a rule muscular weakness or relaxation. 




Slipping patella of the left side. 

Weimuth 1 has collected 66 cases. Of these 32 were of con- 
genital, 14 of traumatic (rupture of internal ligaments), and 20 
of pathological origin (knock-knee). 

Symptoms. — If the slipping of the patella is a frequent occur- 
rence it causes comparatively little pain, but when the parts are 
less relaxed the displacement is likely to be followed by a certain 
amount of effusion into the joint and by the symptoms of a sprain. 
It is usually the result of a misstep or sudden movement when 



Deutsche Zeits. f. Chir., Bd. lxi. Bade, Zeits. f. Orthop. Chir., 1903, Bd. xi. p. 3. 



446 ORTHOPEDIC SURGERY 

the thigh muscle is relaxed or of extreme flexion of the leg. As 
a rule, there is a sense of insecurity and weakness at the knee in 
those who are subject to the accident. 

Treatment. — The treatment varies according to the condition 
of the parts about the joint. If the displacement is the direct 
result of violence the leg should be fixed for a time in a plaster 
bandage, which may be replaced by the adhesive plaster strap- 
ping or a knee-cap. This improvement of the muscular tone by 
exercises is always an important part of treatment whether or 
not support is employed. In cases in which the slipping has 
become habitual and particularly when the ligaments of the 
joint are much relaxed, a light brace should be employed to prevent 
lateral motion and to limit the range of flexion at the joint, if 
this predisposes to the displacement. 

Operative Treatment. — If the position of the patella that pre- 
disposes to the further displacement is a consequence of genu 
valgum the rectification of the deformity will, as a rule, remedy 
the secondary disability. If the displacement appears to be 
caused by laxity of the capsular ligament, as well as by the ab- 
normal position of the patella, an operation for the purpose of 
limiting the mobility and restoring the proper relation of parts 
may be conducted in the following manner: A long, curved 
incision is made about the inner side of the knee, the lower ex- 
tremity of which crosses the ligamentum patellae. The skin-flap 
having been reflected, the contracted capsule may be divided 
on the outer side without disturbing the synovial membrane. The 
patella is then forced inward and the redundant tissue on the 
inner side is folded and sutured, or a section of the capsule may 
be removed, sufficient in size to hold the patella in its proper 
position. As an additional safeguard the semimembranosus 
tendon may be transplanted to the inner border of the ligamen- 
tum patellae as suggested by Backer. 1 In extreme cases the 
tubercle of the tibia, with the attached tendon, may be 
removed and reimplanted on the inner aspect of the tibia, as 
suggested by Wolff and Walsham. The limb should be held in 
the extended position for a time, and it should afterward be 
supported by a brace or knee-cap for several months. Subse- 
quently massage and exercise for restoring the tone of the weak- 
ened muscle should be employed. 

i Zeit. f. Chir., 1904, No. 24 



NON-TUBERCULOUS AFFECTIONS OF KNEE-JOINT 447 

Elongation of the Ligamentum Patellae. 

In certain cases the ligamentum patella may be abnormally 
long, so that the patella lies habitually above its proper position. 
This elongation may be one of the evidences of general relaxation 
of the ligaments of the knee, and thus a predisposing cause of the 
slipping patella or of abnormal mobility at the knee-joint. 

Etiology. — The elongation of the tendon may be a congenital 
peculiarity or it may be acquired. It is most often observed as 
an effect of anterior poliomyelitis or of hemiplegia or paraplegia. 

Symptoms. — The symptoms of elongation of the ligamentum 
'patellae, as distinct from those of the general laxity of the liga- 
ments that is often present, are weakness and disability, usually 
noticeable on walking up or down stairs, or after overexertion. 
Shaffer, who first called attention to the disability from this cause, 
thinks that it may be a predisposing cause of displacement of the 
semilunar cartridges. 1 

Treatment. — In this, as in other forms of insecurity or of 
abnormal mobility at the knee, a brace that allows only antero- 
posterior motion will, as a rule, relieve the symptoms. If the 
ligament is of such a length as to require it, it may be shortened, 
or the tubercle of the tibia may be removed and implanted at a 
lower point, as suggested by Walsham. 2 

Other Congenital Deformities at the Knee. 

Congenital displacements are uncommon. As a rule, they 
are incomplete and are caused by laxity of the ligaments and by 
defective formation of the bones or other parts. 3 

Snapping Knee. 

A very slight form of partial recurrent displacement is the 
snapping or clicking knee not uncommon in early infancy, in 
which the tibia on sudden extension of the limb springs forward 
or rotates outward on the femur with an audible snapping sound. 
This movement appears to be the result of voluntary muscular 
contraction combined with laxity of ligaments and very possibly with 
irregular movements of one or other of the semilunar cartilages. 
In some instances the subluxation appears to cause pain or dis- 

1 Transactions American Orthopedic Association, vol. xi. 

- Medical Weekly, February 17, 1893. 

:i Drehmann, Die Cong. Lux. des Kniegelenks, Zeits. f. Orth. Chir., 1900, Bd. vii. H. 4. 



448 ORTHOPEDIC SURGERY 

comfort. The ability to displace the tibia on the femur by mus- 
cular action is sometimes found in older subjects. In such cases 
it may be the result of injury such as rupture of ligaments or 
irregularity within the joint. Occasionally the snapping may be 
caused by slipping of the biceps tendon. 

Treatment. — The treatment of congenital dislocations or sub- 
luxations of the knee consists in reposition, support, and massage 
of the weak part. The snapping knee may be supported by a 
flannel bandage, or, in the more marked type of laxity of liga- 
ments, it may be fixed for a time in a brace. Complete recovery 
is the rule. 

Congenital Contraction at the Knee. 

Slight limitation of the range of extension of one or both knees 
is not infrequent. As a rule, it is easily overcome by massage 
and manipulation. In the more extreme cases there may be an 
accommodative forward bending of the lower extremity of the 
femur, as in certain cases in which flexion follows anchylosis. 

General Contractions. 

Congenital contraction at the knees of a more marked and 
resistant form may be combined with flexion contraction at the 
hips, or it may be one of a series of contractions at other joints. 
In the latter instance other congenital deformities, such as club- 
hand or foot, or evidences of defective development are usually 
present. For example, certain joints may be fixed in flexion or 
fixed in extension. In some instances the contraction or the par- 
tial anchylosis appears to be due simply to long-continued fixation 
in utero, and to consequent non-development of the muscles. In 
others it appears to be a complication of so-called fcetal rhachitis. 

Treatment. — The treatment consists in regular massage and 
manipulation, with the aim of increasing the range of motion. 
Deformity, if present, may be rectified in the usual manner. 

Prognosis. — The prognosis depends upon the cause of the con- 
traction or fixation. In most instances, under careful and con- 
tinued treatment, the range of motion may be in great degree 
restored. 



CHAPTER XI. 

DISEASES AND INJURIES OF THE ANKLE-JOINT. 

Tuberculous Disease of the Ankle-joint. 

Disease of the ankle-joint is the third in the order of impor- 
tance, although it is far less common than is disease at the knee. 

In five consecutive years 1788 cases of tuberculous disease of 
the joints of the lower extremity were treated at the out-patient 
department of the Hospital for Ruptured and Crippled. In 54.1 
per cent, of these the hip-joint was affected; in 36.2 per cent, 
the knee-joint, and in but 9.7 per cent, the ankle-joint. 




Tuberculous disease of the ankle and tarsus. A, disease of the ankle and subastragaloid 
joints. B, cavity in the os calcis containing sequestrum. 

Pathology. — The pathology of tuberculous disease at the ankle 
differs in no essential particular from that of disease of the hip 
and knee. It does not, therefore, call for special consideration. 
It is of interest to note, however, that abscess is a more common 
complication at this than at the other joints. 

In 30 final results of disease at the ankle reported by Gibney, 1 

1 American Journal of Obstetrics, April, 1880. 
29 



450 ORTHOPEDIC SURGERY. 

abscess was present in 25 (83 per cent.). In 78 final results 
reported by Prendlsburger 1 abscess was present in 68 (87 per 
cent.), as contrasted with a percentage of 69 and 51 at the knee 
and hip, respectively. This greater liability to abscess is very 
possibly apparent rather than actual, since the ankle-joint is so 
superficial that fluctuation may be detected here that would be 
overlooked at the hip. And because the tissues about the joint 
readily allow spontaneous opening at an early period, before 
sufficient time has elapsed to permit of spontaneous absorption. 

Situation of the Disease. — -Otto Hahn 2 investigated the cases 
of tuberculous disease of the ankle and foot treated at Tubingen 
during a period of fifteen years. These cases were 704 in number 
in 685 patients, in 19 both feet having been involved. 

In 309 of the cases the disease was of the ankle-joint. Of 
these 51 per cent, were osteal in origin. The primary focus was 
in the internal malleolus in 11, the external in 7, in both in 5. 
It was in the astragalus in 116 cases. 

In 16 instances the disease of the ankle was secondary to pri- 
mary infection of the os calcis, and in 5 cases both the astragalus 
and the os calcis were diseased. 

Of 88 cases investigated by Stich 3 the ankle-joint was involved 
in 88 per cent., in 45 per cent, the disease being limited to this 
joint. The astragalo-na\icular joint was involved in 29 per 
cent., and the astragalo-calcaneoid joint in 36 per cent. 

Etiology. — The etiology of tuberculous joint disease does not 
require further comment. It may be noted, however, that tuber- 
culous disease at the ankle is relatively more common in later 
childhood and adult life than is the same affection at the knee 
and hip. 

Of 1000 cases of disease of the hip-joint, 12 per cent, were in 
patients more than ten years of age. 

Of 1000 cases of disease of the knee-joint, 25 per cent, were 
in patients more than ten years of age. 

Of 339 cases of disease of the ankle-joint, 30 per cent, were 
in patients more than ten years of age. 4 

Of the 339 patients 177 were males (52.2 per cent.); 162 were 
females (47.8 per cent.). The disease was of the right ankle 
in 173 cases; of the left in 166. 

1 Loc. cit. - Beitrage zur klin. Chir., 1900, Bd. xxvi., H. 2. 

3 Beit. z. klin. Chir., Bd. xlv., p. 587. 

4 Statistics from Hospital for Ruptured and Crippled. 



DISEASES AND INJURIES OF THE ANKLE-JOINT 451 



Age at Incipiency of Ankle-joint Disease in 339 Consecutive Cases 
Treated at the Hospital for Ruptured and Crippled. 



1 year or less 5 

2 years old 42 

3 



24 years old 

25 " 

26 " 

27 " 

28 " 

29 " 

30 " 

31 " 

32 " 

33 " 

34 " 

35 " 

36 " 

37 " 
40 " 

43 " 

44 " 

45 " 



Of 658 patients 412 were males (62 per cent.); 246 were females 
(38 per cent.). In 27 the sex was not stated. 



Age of the Patients Treated for Ankle-joint and Tarsal 
Disease at Tubingen. (Hahn.) 

Males. Females. Total. 

1 to 10 years 45 28 73 

11 " 20 " 149 91 240 

21 " 30 " 89 34 123 

31 " 40 " 32 28 60 

41 " 50 " 37 27 64 

51 " 60 " 35 26 61 

61 " 70 " 18 11 29 

71 " 80 " 6 1 7 

81 " 1 1 

412 246 658 

Symptoms. — The symptoms are usually subacute in character, 
and are often mistaken for sprain or rheumatism. In some 
instances they appear to follow an injury, but in the majority of 
cases in childhood no cause can be assigned. The ankle becomes 
sensitive to sudden movements; the patient limps, and discomfort 
after overuse and pain at night become noticeable. The limp 
differs in character from that caused by hip or knee disease. 
The patient walks with the foot rotated outward, bearing the 
weight upon the heel and upon the inner border, active leverage 
"spring" being avoided. 



452 



ORTHOPEDIC SURGERY 



Deformity. — The primary deformity of ankle-joint disease in 
the subacute cases is valgus, induced apparently by the continued 
use of the limb in the passive attitude. In more advanced cases 
it becomes equino valgus, and when the limb is no longer capable 
of supporting weight, but is held pendent, the equinus edmriofty 
predominates, due partly to the force of gravity and partly to the 
muscular spasm. 




Tuberculous disease of the ankle. 

As has been stated, in the early stage the symptoms are those 
of a persistent, somewhat painful disability at the ankle, causing 
stiffness, limp, and at times pain; later swelling and deformity 
appear. 

Physical Examination. — The joint is usually somewhat enlarged. 
In some instances the swelling is uniform; in others it is localized 
in front or behind one of the malleoli. This swelling is not, 
as a rule, like that of simple effusion into the joint, but the tissues 
have the peculiar elasticity characteristic of thickening and infiltra- 
tion. There is usually a perceptible increase in the local tem- 
perature, and pressure directly upon the malleoli causes dis- 
comfort. The voluntary movements of the joint are restricted, 



DISEASES AND INJUEIES OF THE ANKLE-JOINT 453 

and passive movements show the characteristic reflex muscular 
spasm, limiting both dorsal and plantar flexion. 

Subastragaloid Disease. — If the astragalus is primarily diseased, 
the symptoms are usually first apparent in the ankle-joint, but in 
certain cases the joint between the astragalus and the os calcis is 
first involved, the primary focus being in the os calcis. Disease 
at the subastragaloid joint is usually classed as ankle-joint disease, 
although the swelling is most marked at a point somewhat below 
the malleoli (Fig. 288). 

Fig. 288 




Tuberculous disease of the subastragaloid joint. 

In this form forced lateral motion of the os calcis causes dis- 
comfort, and the range of adduction and abduction of the foot 
is restricted, while dorsal and plantar flexion may remain com- 
pletely free. 

Astragalo-navicular Disease. — In this form the foot is held ip 
an attitude of persistent abduction and if the disease is subacute 
it may be mistaken for rigid weak foot. 

Diagnosis. — The principles of differential diagnosis of tuber- 
culous disease from other affections have been considered in 
detail in the description of disease of the spine and of the larger 
joints. 




The epiphyses cf the lower extremities at the age of six years, showing the effect of oper- 
ative removal of bone at the ankle-joint for tuberculous disease at the age of three years, in 
causing subsequent deformity of the foot and shortening of the limb. Ossification is present 
at birth in the lower epiphysis of the tibia. It begins at the second year in the lower 
epiphysis of the fibula, but not until the fifth year in its upper epiphysis. 



DISEASES AND INJURIES OF THE ANKLE-JOINT 455 

In childhood a chronic, painful disease confined to a single 
joint in which motion is limited by muscular spasm, and in which 
there is a tendency to deformity, is almost certainly tuberculous 
in character. 

In adult life also the same statement applies, and distinguishes 
tuberculous disease from rheumatism, rheumatoid arthritis, or other 
general affections. Forms of infectious arthritis may be differ- 
entiated by the history. Sprains or other injury may be distin- 
guished by the history of the onset and by the absence of local 
signs of serious disease. In rigid flat-foot the symptoms are local- 
ized at the mediotarsal joint. It should be borne in mind, also, 
that the pain from a weak or injured foot is experienced, as a 
rule, only when it is in use; whereas, in tuberculous disease of the 
bone, pain is common when the part is not in use, and it may 
be particularly troublesome at night. 

Treatment. — In disease of this, as of other joints, functional 
rest is indicated. This necessitates fixation of the joint and 
stilting of the limb, efficient traction being manifestly impossible. 
The foot should be fixed in a light plaster bandage extending 
extremities of the toes to the upper third of the leg, at a right 
angle with the leg and in an attitude of slight inversion, in order 
to guard against the tendency toward valgus. This deformity 
is very common after the cure of the disease, and it often subjects 
the patient to the additional discomfort of progressive flat-foot. 

Reduction of Deformity. — If the foot has become distorted 
before the patient is brought for treatment, the plaster bandage 
may be applied in the attitude of deformity, and at the subse- 
quent applications of the dressing, when the muscular spasm is 
lessened, gentle manipulation will gradually overcome the mal- 
position. In resistant cases immediate reduction of the deformity 
under anaesthesia may be advisable. Throughout the entire 
course of treatment the greatest attention must be paid to the 
attitude. Deformity is easily prevented, but is often very diffi- 
cult to correct, especially during the later stages of the disease, 
when' the tissues are infiltrated and sensitive, and especially if 
discharging sinuses are present. 

Other retentive appliances may be employed, but they are 
inferior to a properly applied bandage, which holds its place by 
accuracy of adjustment, which most effectively prevents motion, 
and which exercises a certain degree of compression upon and 
general support of the swollen joint. The bandage is usually 
renewed at intervals of a month, but it may be retained indefi- 



456 OB THOPEDIC SUBGEB Y 

nitely if it is properly protected by a light shoe or slipper. The 
Bier method of passive congestion may be applied at the ankle 
by means of a bandage above the upper border of the plaster 
support. And the adhesive plaster strapping may be used beneath 
the plaster bandage if local compression and more comprehensive 
support is desired. 

The most satisfactory brace to serve as a stilt in connection 
with the local support is the Thomas brace, which has been 
described in the section on disease of the knee-joint (Fig. 281). 

When patients are treated efficiently the discomfort or incon- 
venience attending the disease is slight. As a rule, the swelling 
of the joint becomes more localized and finally an abscess appears 
beneath the skin. It is then advisable to remove the fluid and 
other contents by means of a simple incision. In most instances 
a sinus persists for a time. If the discharge is slight, the part 
may be dressed with ichthyol, balsam of Peru or other applica- 
tion, and the whole enclosed again in the plaster bandage; or, if 
it be more profuse, an opening may be made and the dressing 
applied outside the plaster bandage. When the stage of recovery 
is reached, stilting apparatus may be discarded, the patient being 
allowed to bear the weight on the foot, protected by the plaster 
bandage or other support. 

Operative Treatment. — Early operation, especially of a gouging 
character, should be avoided. An effective operation of this 
class often involves the sacrifice of bone that would be spared 
in the natural cure, and it entails an irregularity in the growth 
and causes deformity in after-life that may be irremediable (Fig. 
289). 

Similar operations in the, treatment of fistula?, or abscess, while 
the tissues are thickened and oedematous, and while the disease 
within the joint is active, should be postponed until the process 
of repair is more advanced. During the stage of convalescence, 
however, cure may be hastened by the removal of persistent foci 
of disease, or sequestra in the bone, or tuberculous tracts in the 
overlying soft parts. 

In the adult or adolescent, and in exceptional cases in child- 
hood, operative removal of the disease may be indicated. If it 
is confined to the ankle-joint, the removal of the astragalus, which 
is usually the primary seat of infection, is the operation of choice. 

The operation is performed under the Esmarch bandage; a 
curved lateral incision is made passing beneath the external 
malleolus from the neighborhood of the tendo Achillis to the 



DISEASES AND INJURIES OF THE ANKLE-JOINT 457 

anterior aspect of the joint. The lateral and capsular ligaments 
are divided, after which the foot may be displaced inward. The 
astragalus is exposed and it may be removed easily by dividing 
the ligaments about its head and its attachments to the os calcis. 
All the diseased tissue in the soft parts and in the bone must be 
removed thoroughly. If the disease has not extended to the 
tarsus, and if it seems to have been completely removed, the 
wound may be closed, but in most cases it should be packed for 
a time with gauze. The after-treatment is conducted as if the 
operation had not been performed, support and fixation being 
continued until it is evident that the disease is cured. 

Removal of the astragalus does not interfere to a marked extent 
with the function of the foot, nor does it cause noticeable de- 
formity. As a primary operation, permitting inspection and the 
opportunity for thorough removal of all disease in the neighbor- 
ing parts, it should always be performed in preference to exten- 
sive gouging, which is, as a rule, of little avail. It may be men- 
tioned in this connection that motion in an anchylosed joint may 
be restored by the removal of the astragalus. 

Prognosis. — Disease at the ankle is not only less common, but 
it is less dangerous than that of the larger joints, because it is 
remote from important structures, and because there is less oppor- 
tunity for the burrowing of infected abscesses. The duration 
of the disease here is, as a rule, shorter than at the knee or 
hip, and the final results in childhood are almost always excel- 
lent. Often free motion is retained at the ankle, and even if the 
astragalus be fixed by disease the mobility in the other joints of 
the foot is sufficient to compensate very effectively for the anchy- 
losis. Shortening of the limb is of comparatively little conse- 
quence. It is not often more than an inch, and it may be absent. 
The growth of the foot is often considerably retarded, partly from 
disuse and partly because of the destructive effect of the disease 
upon the tarsal bones. 

In the 30 cases reported by Gibney, treated expectantly, in 
which the mechanical treatment was far from effective, 6 patients 
recovered with normal motion; 11 with practically normal func- 
tion. In 7 there was good motion. In 6 there was anchylosis, 
and in 3 persistent valgus. In all the limb was efficient. In 20 
instances there was no limp, and in but 1 case was it marked. 
In no instance was a crutch, cane, or other support used. The 
average duration of the disease was three years and three months, 
a minimum of one year, a maximum of six years. There were 



458 ORTHOPEDIC SURGERY 

2 deaths, of which but 1 was dependent upon the disease, septi- 
caemia being the cause assigned, though it is stated that practically 
all the bones of the tarsus were involved. In this case amputa- 
tion was evidently indicated. 

Tuberculous Disease of the Tarsus. 

Tuberculous disease of the joints of the foot, not involving the 
ankle, is not uncommon. 

In 386 of the 704 cases reported by Hahn, the disease was 
limited to the foot. In 141 cases the mediotarsal joint was in- 
volved; in 51 of these the disease was confined to this joint; in 
46 the ankle was involved; in 29 the disease extended forward 
to the tarsometatarsal articulation, and in 16 the three joints 
were diseased. In 78 cases the tarsometatarsal joint was involved, 
in 33 of which the disease did not extend beyond this articulation. 

Disease of Individual Bones.— In these cases the distribution 
was as follows: 

The astragalus 170; disease confined to the single bone in 8 

The calcaneum 200; " " " " " 87 

The cuboid 116; " " " " " 18 

The scaphoid 82; " " " " " 2 

The cuneiform bones .... 86; " *' " " " 8 

i one-half of these the disease was 
of the first metatarsal, either alone 



Metatarsal bones 45; -, , 

or in connection with the adjoin- 
ing cuneiform bone or phalanx. 

In a total of 1231 cases, including these and others reported 
by Audry, 1 Koenig, 2 Mondan, 3 Munch, 4 Spengler, 5 Vallas, 6 Czerny, 7 
and Dumont, 8 the relative frequency of the disease in the bones 
of the foot and ankle appeared to be as follows : 

Malleoli ... 96, 7.7 per cent. Scaphoid . . . 110, 8.9 per cent. 

Astragalus. . . 291,23.6 " Cuneiform bones . 109,8.8 

Calcaneus . . . 339, 25.9 " Metatarsus . . . 110, 8.9 

Cuboid . . . 154, 12.5 " Phalanges ... 22, 1.7 

In disease at this point limited to the astragalo-navicular joint 
the swelling is localized in front of the ankle on the inner side 
of the foot. Adduction is restricted, and the foot is often fixed 
in an attitude of persistent abduction. Such cases may be mis- 
taken for rigid weak foot. 

Disease of other bones of the tarsus is indicated by the local 
swelling and sensitiveness. The disease sometimes involves the 

1 Revue de Chir., 1891. 2 Schmidt's Jahrb., 1884, Bd. cciv. 

3 Deutsche Chir., ]., 66. 4 Deutsche Zeits. f. Chir., 1879, Bd. ad. 

6 Ibid., 1897, Bd. xliv. 6 Deutsche Chir., 1., 66. 

7 Volk. S. Klin., v., No. 76. 8 Deutsche Zeits. f. Chir., 1882, Bd. xvii. 



DISEASES AND INJURIES OF THE ANKLE-JOINT 459 

shaft of a metatarsal bone, or one of the phalanges, causing 
expansion and destruction, "spina ventosa." 

Treatment of Tarsal Disease. — Disease of the tarsus shows 
a marked tendency to extend from one bone to another until the 
entire foot is involved. Consequently if an early diagnosis is 
made of a distinctly localized process prompt removal of the dis- 
eased bone is indicated; but in most instances the disease is too 
extensive to permit of its radical removal. In such cases opera- 
tive intervention is contraindicated, and the treatment by protec- 
tion similar to that employed in disease of the ankle, is indicated. 
In childhood the prognosis is very good even when the disease is 
extensive, but in adult life amputation of the foot may be advis- 
able because of the time required to assure a natural cure and 
because an artifical leg provides a better support than a stiff and 
sensitive extremity. Amputation is almost always indicated, 
if there is co-existent disease of the lungs. 

Sprain of the Ankle. 

The ankle is, from its position, especially liable to injury; in 
fact, the term "sprain" is popularly associated with this joint. 

A sprain is most often caused by an unguarded movement, by 
which the foot is turned suddenly inward or outward, with suffi- 
cient force to injure the synovial membrane, to rupture some of 
the fibres of the muscles, to strain tendons and tendon sheaths, 
and even to rupture ligaments. If the foot is twisted inward 
the injury is most marked on the outer side of the joint; if out- 
ward, on the inner side of the ankle. In the slighter degrees of 
sprain the injury may be confined to the tissues about the joint, 
but in most instances there is effusion within the capsule, even 
hemorrhage when injury has been severe. 

Symptoms. — The immediate symptoms of sprain are pain, 
often intense, of a throbbing character, swelling, heat, and in 
many instances discoloration of the surrounding parts, even 
extending over the leg and foot. 

Treatment. — If an opportunity for immediate treatment is 
offered, the swelling and the effusion of blood may be restrained 
by the application of elastic stockinette bandages from the toes 
to the knee. As much compression is exercised as the comfort 
of the patient will allow, and the bandage should be made suffi- 
ciently thick to prevent painful motion. If the injury has been 
severe and if the part is very sensitive to motion or jar, the joint, 



460 ORTHOPEDIC SURGERY 

having been protected with cotton, may be fixed in a light plaster 
bandage. This may be cut down the front to allow for daily 
massage of the foot, ankle, and leg, which is of great service in 
hastening the absorption of the effusion. 

The use of hot air, hot and cold water, and static electricity, 
and the like are of service also in relieving the discomfort and 
more especially in stimulating the circulation, upon which repair 
depends. 

By far the most effective treatment during the stage of recovery 
and as an immediate application for sprains of slighter degree, is 
the adhesive plaster strapping which has been popularized by 
Gibney. His method is as follows: Strips of adhesive plaster 
about three-quarters of an inch in width and from nine to eighteen 




A method of applying adhesive plaster strapping for sprain of the ankle. 

inches in length are prepared. A long strip is placed with its 
centre beneath the heel, and the two ends are carried upward 
over the malleoli, to a point at the junction of the middle and 
lower thirds of the leg. A second strip is placed at the posterior 
extremity of the heel, and the two ends are carried forward some- 
what beyond the tarsometatarsal junction on either side. Another 
strip is then placed by the side of the first, and the fourth by the 
side of the second, until the entire ankle is smoothly covered, except 
for a space about two inches in width directly on the front of the 
ankle. One takes particular care to make the plaster fit well 
about the malleoli and reinforces it at the points of greatest sen- 
sitiveness. A light bandage is then applied and the patient is en- 
couraged to use the foot in walking. The plaster may be applied 



DISEASES AND INJURIES OF THE ANKLE-JOINT 461 

in a variety of ways; a satisfactory method is as follows, after the 
preliminary massage for the purpose of reducing the swelling: 
One end of a strip of adhesive plaster about three feet long 
and three inches wide is applied to the lateral aspect of the leg 
just below the knee-joint; it is carried down the side of the leg 
over the malleolus, beneath the heel and arch, and up the other 
side to a point opposite the beginning where it is fixed by a cir- 
cular band about the calf. If the sprain is of the outer side of 
the ankle, sufficient tension is made upon the outer half of the 
plaster to hold the foot slightly abducted. If, as is more common 
the sprain is of the inner side, the inner half is drawn firmly be- 
neath the arch, carrying the foot toward inversion so that all strain 
may be removed from the sensitive part. This band of plaster 




The stockinette bandage. 

is reinforced by one or more so that the lateral aspect of the ankle 
is completely covered. And in addition the entire ankle is then 
enclosed with narrow, overlapping strips which cover all the tissues 
well beyond the sensitive area. The foot and leg are then bandaged 
to assure the adhesion of the plaster. When the joint is firmly 
held by the supporting plaster the patient can, as a rule, walk 
with comfort; and he is encouraged to do so, for functional use, 
provided it does not cause additional injury, is the most effective 
stimulant of the circulation; thus the patient applying, as it were, 
an automatic massage, cures himself. 

As the swelling subsides the plaster strapping wrinkles, and it 
must be renewed, about three applications being required, as a 
rule, the last of which is allowed to remain until all of the symp- 
toms have disappeared. Vigorous massage before applying the 



462 ORTHOPEDIC SURGERY 

new dressing is of service in hastening the cure. It is perhaps 
needless to state that a preliminary shaving of the part will add 
somewhat to the comfort of the patient. 

Chronic Sprain. 

A chronic sprain may be the result of an inefficiently treated 
acute injury, in which an improper attitude originally assumed 
to spare the sensitive part finally becomes habitual. In other 
instances persistent disability may be the result of fixation of the 
joint for too long a time in splints. Such disuse causes atrophy 
of the muscles and of the bones as well (see Atrophy, page 244), 
while the effused material within and without the joint remains 
because of the imperfect circulation. The same disability may 
follow simple disuse of the injured part. It is more often observed 
in nervous individuals who exaggerate the importance of the injury 
and the discomfort that it causes. In such cases the limb may 
be discolored by venous congestion, the foot may be cedematous 
and the movements may be limited by adhesions or by muscular 
adaptation to the habitual attitude. 

In other instances the original injury may have caused a slight 
subluxation of the astragalus, sufficient to throw the foot into an 
attitude of abduction, in which it has become fixed by the second- 
ary changes in the muscles and ligaments. In some cases of this 
class the original sprain was at the mediotarsal or at the sub- 
astragaloid joint, and its effect has been traumatic weak foot. It 
may be stated, also, that many of the so-called sprains of the ankle 
are simply injuries of a weak foot, a disability to which the treat- 
ment should be directed. (See the Weak Foot.) 

Treatment. — Treatment must be conducted with the aim of re- 
storing the normal range of motion and so supporting the part 
that normal functional use may be permitted. If adhesions have 
formed and if the foot is persistently held in an abnormal attitude, 
forcible manipulation under anaesthesia may be required as a 
preliminary treatment, followed by fixation for a time in a plaster 
bandage, in the attitude directly opposed to that which has been 
habitual. In this class of cases the habitual attitude is usually 
one of equino valgus; the foot should be fixed for a time, therefore, 
in a plaster bandage in a position of extreme varus, at a right angle 
with the leg, and upon it the patient is encouraged to bear his 
weight both in standing and walking. When all discomfort has 
disappeared, a support, usually a light leg brace to prevent lateral 



DISEASES AND INJURIES OF THE ANKLE-JOINT 463 

motion, and if the arch is depressed a foot plate also, should be 
worn for a time. The most effective curative agent is functional 
use, but massage, hot air, passive manipulation, and exercises 
are valuable accessories. 

Injuries of this class are very amenable to treatment, con- 
ducted with the aim of restoring normal function, if proper sup- 
port is provided during the period of pain and weakness. 

Tenosynovitis. 

The sheaths of the tendons about the ankle-joint, if involved 
in a sprain of the ankle, may cause persistent interference with 
function; or strain of a tendon and of its sheath may cause symp- 
toms of disability when the joint is uninjured. The symptoms of 
acute tenosynovitis are discomfort on motion of the affected tendon, 
and this motion may be accompanied by a peculiar creaking which 
is apparent on palpation. In many instances there is slight local 
swelling and sensitiveness to pressure about the affected part, and 
the movements of the foot that call the muscle into action are painful. 

The arrangement of the tendon sheaths should be borne in 
mind. At the ankle-joint all the tendons are provided with sheaths ; 
on the front of the foot are three — the sheath of the tibialis anticus, 
which extends from a point about two inches above the extremity 
of the malleolus to the navicular bone (Fig. 292); that of the 
extensor longus hallucis, from the annular ligament to the head 
of the first metatarsal, and the common sheath for the extensor 
communis digitorum, extending from a point about half an inch 
above the malleoli to about one inch below the annular ligament. 
Behind the internal malleolus are the common sheaths of the tibialis 
posticus and flexor longus digitorum, beginning about an inch 
above the extremity of the malleolus and extending to the astragalo- 
navicular junction and that of the flexor longus hallucis of 
about the same extent (Fig. 293). Behind the outer malleolus 
is the sheath of the two peronei, beginning one inch above the mal- 
leolus, dividing into two portions for the two tendons and ending 
just behind the tuberosity of the fifth metatarsal bone (Fig. 294). 

Treatment. — Simple traumatic tenosynovitis should be treated 
by rest and by compression. An effective treatment is strapping 
with adhesive plaster, so applied as to prevent the movements of 
the foot that cause discomfort. In more painful and persistent 
cases the use of a plaster bandage to assure absolute rest may be 
necessary. Cautery applied over the affected part is of service. 



464 



ORTHOPEDIC SURGERY 



Chronic tenosynovitis may follow injury or it may be the result 
of gonorrhoea or other infectious disease. In chronic cases when 
the palliative treatment is ineffective, thorough removal of the 
affected sheath is indicated. (See Achillobursitis.) 

Tuberculous Tenosynovitis. — A persistent and increasing 
swelling of a tendon sheath always suggests tuberculous disease. 





The internal annular ligament of the ankle and the arti- 
ficially distended synovial membranes of the tendons 
which it confines. (Testut, from Gerrish's Anatomy.) 



The anterior annular ligament of 
the ankle and the synovial mem- 
branes of the tendons beneath it 
artificially distended. (Testut, from 
Gerrish's Anatomy.) 




The external annular ligament of the ankle and the arti- 
ficially distended synovial membranes of the tendons 
which it confines. (Testut, from Gerrish's Anatomy.) 



DISEASES AND INJURIES OF THE ANKLE-JOINT 465 

In such instances the sac is thickened and often contains the 
so-called rice bodies. Prompt and complete removal of the dis- 
eased sheath is indicated, and by this means a permanent cure 
may be attained in most instances. 

Swelling about the Ankles. — Occasionally either in combina- 
tion with weak feet or independent of it, one finds a distinct swelling 
about the ankles most marked in front of the external malleoli. 
This is apparently an extension from the joint made up of synovial 
and fatty tissue. In most instances the patients are fat and the 
apparent cause is overweight. 




The patients usually complain of weakness and discomfort. 
The treatment aside from reduction of weight, and support for the 
weakened arch, is massage, strapping and bandaging. The oper- 
ative removal of the swollen tissue is indicated in obstinate cases. 



Other Affections of the Ankle-joint. 

The ankle-joint may be the seat of an infectious arthritis; it 
may be involved in an osteomyelitis of the tibia. It may be 
one of the joints affected in chronic rheumatism or rheumatoid 
arthritis, and occasionally Charcot's disease may appear in this 
situation. The principles of the treatment of these affections 
have been indicated elsewhere. 



CHAPTEE XII. 

DISEASES AND INJURIES OF THE ARTICULATIONS OF THE 
UPPER EXTREMITY. 

Tuberculous Disease of the Shoulder-joint. 

Disease at the shoulder is very uncommon in childhood. In 
a total of 453 cases of tuberculous disease treated at the Vander- 
bilt clinic 210 were cases of Pott's disease. In 6 of the remain- 
ing 243 cases the disease was of the shoulder-joint (2.5 per cent.). 

In 1883 consecutive cases of joint disease — Pott's disease being 
excluded — treated in the out-patient department of the Hospital 
for Ruptured and Crippled in a period of five years, the shoulder- 




Section of the shoulder-joint at the age of eight years. (Schuchardt.) Ossification 
appears in the epiphysis of the head of the humerus at the end of the first year; a second 
point appears in the greater tuberosity during the second year. These unite between the 
fourth and sixth years. Ossification is complete between the eighteenth and twentieth years. 

joint was involved in 38 instances (2 per cent.). In 1900 cases 
of joint disease treated at Billroth's clinic, the shoulder was in- 
volved in 14, or less than 1 per cent. 

Pathology. — The disease usually begins in the head of the 
humerus. In 32 observations on adults recorded by Mondan and 
Andry, 1 the primary disease was of the head of the humerus in 
23 cases, of the humerus and scapula in 4, of the scapula alone 
in 1, and in 3 instances it appeared to be primarily synovial. 



Revue de Chir., 1892. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 467 

In the majority of cases abscess forms and comes to the surface 
near the insertion of the deltoid muscle. In advanced cases the 
tissues of the axilla and of the adjoining thorax may be infiltrated 
and perforated by numerous sinuses. Not infrequently the dis- 
ease is of the form called caries sicca, in which there is no swell- 
ing, but progressive destruction of the head of the humerus by 
granulation tissue. This form is characterized by extreme mus- 
cular atrophy and by practical anchylosis. 

Statistics. 

Age at Incipiency of Disease at the Shoulder-joint in Sixty-two 
Consecutive Cases Treated at the Hospital for Ruptured and 
Crippled. 



1 year or less 1 13 years old 

2 years old 6 15 

3 " 1 18 

4 " 3 19 

5 " 3 20 

6 " 1 23 

7 " 3 26 



10 " 1 

11 " 5 

12 " 4 



Males, 38; females, 24; right, 35; left, 27. 

Townsend 1 made a detailed report on 21 cases treated at the 
Hospital for Ruptured and Crippled during the years 1889 to 
1893. Ten of these were less than ten years of age; 7 were 
between ten and twenty, and 4 were more than twenty. The 
youngest patient was three and a half and the age of the oldest 
was thirty-five years. In 5 cases the disease was secondary to 
disease of other parts; in 1 case to Pott's disease; in 2 to hip 
disease, and in 2 to disease of the knee-joint. 

Symptoms. — The history of the case will show the persistent 
and progressive character of the disability, but the symptoms 
characteristic of tuberculous disease are far less marked at the 
shoulder than at other joints. This is explained by the fact that 
the upper extremity is not subjected to weight bearing and be- 
cause the mobility of the scapula upon the thorax lessens the 
injury caused by unguarded movements of the arm. This double 
joint at the shoulder masks the interference with the function of 
the joint, and the strain caused by overuse may be lessened by 

1 Transactions AmericanlOrthopedic Association, vol. vii. 



468 



ORTHOPEDIC SURGERY 



the unconscious restraint that the patient can exercise upon 
motion at this joint. In fact, even when absolute anchylosis is 
present the patient may think that motion is but moderately 
restricted. 

The symptoms of the disease may be classified as pain, sensi- 
tiveness, restriction of motion, atrophy. 

There is usually a dull ache about the joint, with occasional 
neuralgic pain referred to the elbow and arm. The discomfort 




Tuberculous disease of the shoulder-joint. 



is increased by movements that pass beyond the limits allowed 
by the mobility of the scapula, especially on attempting to rotate 
the humerus, as in clothing one's self or brushing the hair. The 
joint is sensitive to pressure; thus the patient finds that he cannot 
lie on the affected side at night. 

The normal range of motion between adduction and abduction is 
about 90 degrees, and between flexion and extension somewhat less. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 469 

On examination the limitation of motion caused by muscular 
spasm will be evident if the scapula is fixed, so that movement 
of the joint can be tested. 

Pressure upon the head of the humerus usually causes pain, 
and in many instances local heat and swelling are present. The 
atrophy of the shoulder muscles is often extreme and that of the 
other muscles of the limb is well marked. 

As has been stated, abscess is a common accompaniment of the 
disease, and in such cases the tissues about the joint are swollen 
and infiltrated. In other instances there is progressive destruc- 
tion of the head of the humerus without abscess formation (caries 
sicca). In cases of this type the flattening of the shoulder may 
be so extreme as to be mistaken for subcoracoid dislocation. 

Treatment. — The treatment of the disease here as elsewhere 
is rest. To assure absolute functional rest the wrist should be 
attached to the neck by a sling, the elbow being flexed to an 
acute angle; the arm is then fixed to the thorax by a bandage. 
Local rest and compression may be still further assured by strips 
of adhesive plaster applied over the shoulder and extending to 
the back and chest; or a shoulder-cap of leather or plaster may 
be employed. This method of fixing the bare arm to the chest is 
the only one that assures continuous rest, as changes of the clothing 
necessitate movement of the joint. During the acute phases of 
the disease the arm may be supported in the attitude of extreme 
abduction by means of a triangular splint or pad. This position 
is often that of greatest comfort to the patient. Direct traction 
is not often employed, as support of the pendent limb is usually 
preferred by the patient. 

Operative Treatment. — If the focus of disease seems to be local- 
ized, an exploratory operation for its early removal may be in- 
dicated. Excision of the joint in the adult cases, or arthrectomy 
in younger subjects, may be advisable when suppuration is per- 
sistent or when for other reasons it may seem best to attempt to 
remove the diseased area. 

Prognosis. — The duration of the disease appears to be from 
two to five years. The death-rate is higher than in disease of 
the joints of the lower extremity, because a larger proportion of 
the patients are adults, and in this class tuberculosis of the lungs 
is not an infrequent complication. 

It is impossible to speak positively of the results of the con- 
servative treatment of disease of the shoulder. The disease is 
uncommon, and protection is almost never applied in the in- 



470 



ORTHOPEDIC SURGERY 



cipient stage, nor efficiently and persistently employed to the 
end. The ordinary result is, therefore, anchylosis, usually of 
the fibrous rather than of the bony variety. 

If the disease appears in early life the growth of the limb may 
be seriously interfered with; an inch or more of shortening from 
this cause is not uncommon. 

Tuberculous Disease of the Elbow-joint. 

Tuberculous disease of the elbow-joint is the fourth in order 
of frequency, preceding the shoulder and the wrist. Of 1883 
consecutive cases of joint disease treated at the Hospital for Rup- 
tured and Crippled 56 were of the elbow. 

Pathology. — The primary disease is in most instances osteal 
as in 92.8 per cent, of the cases investigated by Scheimpflug, 44 
in number. 1 The original focus of infection is somewhat more 
often of the ulna than of the humerus. Of the ulna the olecranon 
process, and of the humerus the external condyle, appear to be 
the points of election. Disease of the head of the radius is com- 
paratively infrequent. In 119 cases reported by Oilier the olec- 
ranon was involved in 73, the humerus in 33, and the radius in 
12 instances. 2 And in the cases investigated by Kummer, 3 and 
Middledorpt, 4 the ulna was more often the seat of the primary 
disease than was the humerus, but in 81 cases treated in Koenig's 
clinic the primary disease was of the humerus in 43, of the olecranon 
in 36, and of the radius in 2 instances. 5 



Statistics. 

Age at Incipiency of Disease at the Elbow-joint in Fifty-nine 
Consecutive Cases Treated at the Hospital for Ruptured and 
Crippled. 



1 year or less 2 

2 years old 5 



13 years old 

14 

15 

17 

19 

21 

23 



Males, 28; females, 31; right, 27; 



Total 
left, 32. 



1 Festschrift fur Billroth, 1892. 

2 Karewski, Chir. Krank. des Kindersalters, p. 268. 

3 Deutsche Zeits. f. Chir., Bd. xxvii. 

4 Archiv f. klin. Chir., Bd. xxxiii. 

6 Koenig, Lehrbuch Spec. Chir., Berlin, 1900. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 471 

Symptoms. — The symptoms are those of a chronic, persistent, 
destructive disease. Pain, local sensitiveness and swelling, stiff-- 
ness, deformity, atrophy. 

The pain is usually localized at the elbow. It is increased by 
sudden movements, and as the bones are so superficial there is 
usually local sensitiveness to pressure, most marked over the seat 
of the disease. In the early stage the swelling is slight, and it 
is of the peculiar elastic character due to thickening of the tissue 

Fig. 298 




Tuberculous disease of the elbow-joint 



rather than to effusion within the capsule, but as the disease 
progresses the joint assumes the peculiar spindle shape charac- 
teristic of white swelling. The degree of elevation of the local 
temperature depends upon the activity of the disease. The most 
important physical sign is the restriction of motion due to the 
characteristic muscular spasm which becomes evident when the 
limit of painless motion is passed. The limitation of extension 
and flexion gradually increases, and finally the limb becomes 
fixed in an attitude midway between flexion and extension, with 



472 



ORTHOPEDIC SURGERY 



the forearm in an attitude between pronation and supination. 
This is the characteristic deformity of the disease. 

Atrophy of the muscles of the arm and forearm is present, 
corresponding to the intensity and duration of the disease and to 
the functional disability of the joint. 

Treatment. — The treatment here as elsewhere consists essen- 
tially in placing the joint at rest in the attitude at which anchy- 
losis or limitation of motion will least inconvenience the patient, 




Tuberculous disease of the elbow-joint; the stage of recovery. 



and at the elbow-joint this is practically at right angular flexion 
(Fig. 299). 

In the treatment of young children the wrist may be attached 
closely to the neck by means of a sling, with the elbow at an acute 
angle (the Thomas method) within the clothing. Or a light 
plaster bandage may be used to fix the joint, the wrist being sup- 
ported by a sling. This enables the patient to dress himself 
without moving the part and it protects the joint from injury. 
Other forms of splints may be employed, but the plaster bandage 
answers every purpose. It should, of course, extend from the 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 473 

axilla to the hand, and in sensitive cases it may include the hand 
also. 

Reduction of Deformity. — In many instances the arm is fixed in 
the semi-extended attitude when the patient is brought for treat- 
ment. In this class of cases a simple and effective means of 
reducing deformity is that suggested by Thomas. When it is 
impossible to bring the wrist to the neck, one bends the neck 
toward the wrist and attaches the two by a bandage that the 
patient is unable to remove. From this uncomfortable attitude the 
patient can free himself only by drawing the arm toward the neck 
and thus reducing the deformity. At the next visit the same 
procedure is repeated, until finally the elbow is flexed to the required 
degree. A permanent sling may be constructed of a leather 
wrist-band and a tube of leather to pass about the neck, through 
which the bandage may be drawn; thus the pressure on the wrist 
and neck may be lessened. In the very resistant cases reduction 
of deformity under anaesthesia may be required, but this is not 
often necessary. 

Prognosis. — If the case is treated at an early stage the prog- 
nosis in childhood is good. The duration of treatment may be 
estimated at two years or more, and retention of a fair range of 
motion may be expected. Anchylosis in the right-angled position 
does not, however, seriously inconvenience the patient, provided 
the cure is absolute. The loss of growth is usually less than 
when the upper epiphysis of the humerus has been destroyed, the 
final disproportion depending, of course, upon the age of the 
patient and upon the degree of function that is preserved. 

Operative Treatment. — In some instances it is possible to re- 
move small foci of disease from the humerus, or from the ulna, 
before the joint is involved. The position of the disease may be 
indicated by sensitiveness or swelling, and in older subjects a 
Roentgen picture may demonstrate its position accurately. 

Excision of the Elbow. — Excision is often advisable in adolescent 
or adult life, because by this procedure, in most instances, the 
disease may be cured in a definite time and because a movable 
joint may be assured. 

Oschman has recently investigated the final results of the opera- 
tion performed on this class at KocherV clinic at Berne, 1872- 
1897. In 40 of 45 cases the operation was performed for tubercu- 
lous disease. There were no deaths referable to the operation. 
Of the entire number of cases 15 were dead, but 11 of these survived 

1 Archiv f. klin. Chir., Bd. lx., H. 2 



474 



ORTHOPEDIC SURGERY 



the operation for from five to twenty-years. Eight of the deaths 
were due to tuberculosis, 2 to other causes, and in 5 the cause 
of death was unknown. In 96 per cent, of the cases the local 
disease was cured. In 68 per cent, of the cases- the patients were 
able to use the limb at hard labor, and in the others it was efficient 
for light work. In 6 cases there was subluxation or luxation; in 5 
the joint was not firm. In 59 per cent, the motions were practically 
normal. In 11 per cent, the joint was anchylosed. 





^ A 




w 


m 


fl 


W" ^ 


Wk- 


W r """' ■'" 



Tuberculous disease of the wrist and knee-joints, showing the characteristic deformities 
in neglected cases of a severe type. 

Tuberculous Disease of the Wrist-joint. 

Disease of the wrist-joint is very uncommon in childhood. In 
a total of 3105 cases of tuberculous disease treated in the out- 
patient department of the Hospital for Ruptured and Crippled 
during a period of five years, 98 were of the upper extremity, and 
in but 4 of these was the wrist-joint involved. Of 43 cases in 
which the joint was resected by Oilier, the youngest patient was 
thirteen years of age. 

Of 990 cases of disease of the joints in childhood, reported by 
Karewski, the wrist was involved in 31. 1 



Chir. Krank. des Kindersalters, Berlin, 1S94. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 475 

Disease of the wrist in older subjects is less infrequent, although 
at 'all ages it is rare as compared with disease in other joints. 
Tuberculous disease of the metacarpus and phalanges (spina 
ventosa) is, however, far more common. 

Age at Incipiency of Disease at the Wrist-joint in Eighteen 
Consecutive Cases Treated at the Hospital for Ruptured and 
Crippled. 



2 years old . 


. . . 1 


19 


years 


old ... . 


. . . 2 


6 " . . . . 


. . . 1 


20 






. . . 2 


9 " ... 


. . . 1 


25 






. . . 2 


12 "... 


. . . 2 


26 






. . . 2 


14 "... 


. . . 1 


27 




' 


. . . 1 


16 "... 


... 2 








— 


17 "... 


. . . 1 






Total . . 


. . . 18 



Males, 11; females, 7; right, 12; left, 6. 

Symptoms. — The symptoms of tuberculous disease of the wrist 
are, as in other situations, pain, local swelling, and sensitiveness, 
limitation of motion, caused by muscular spasm, and atrophy. In 
advanced cases the hand is usually flexed somewhat upon the arm. 

Treatment. — The treatment of this, as of other joints, is func- 
tional rest, with support in the attitude in which anchylosis or 
limitation of motion will cause the least inconvenience. A light 
plaster bandage extending from the elbow to the tips of the fingers, 
applied over a flannel bandage drawn as tight as the comfort of the 
patient will permit, is a satisfactory support; or a leather splint 
or other form of appliance may be used. The hand should be 
held in an attitude of moderate dorsal flexion, which will permit 
the flexor muscles to close the fingers easily if the wrist becomes 
fixed by the disease. If flexion deformity is present it should 
be corrected by degrees, with each application of the bandage, 
until the desired attitude is attained (Fig. 302). The flannel 
bandage exercises a certain amount of compression upon the wrist , 
which seems to be of benefit, and in certain instances this com- 
pression and fixation may be still further increased by the appli- 
cation of adhesive plaster. Bier's treatment by passive congestion 
may be applied, and according to reports it is especially efficacious 
at this joint. When the disease of the joint is quiescent, or in the 
stage of recovery, the bandage or splint may be shortened to allow 
the patient to use the fingers. 

Prognosis. — The prognosis as regards function in cases treated 
promptly in childhood should be good. In the adult cases wrist- 
joint disease seems to be very often complicated by disease of the 
lungs; thus the prognosis as to life is often bad. In this class 



476 ORTHOPEDIC SURGERY 

of cases early excision is usually recommended, with amputation 
as a final resort. 

Spina Ventosa. 

Central disease of the long bones of the foot and hand is the 
most common form of diaphyseal tuberculosis. While the cortical 







Fig 


301 




f 


i 




g 














• 










It 










w Jt 










^^^Dm^t^ 





















Tuberculous disease of the right wrist-joint, showing the swelling and the limitation of 
motion. 




Treatment of tuberculosis of the wrist-joint by plaster-of-Paris, showing the proper 
attitude. 

substance is destroyed from within it is often replaced in part 
by a formation of periosteal bone from without, which in turn may 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 477 

be destroyed by the advancing disease. In the early cases the 
affected bone is enlarged, spindle-shaped, and is somewhat sen- 




Tuberculous disease of the carpus. 
Fig. 304 




Tuberculous disease of the left wrist-joint. The irregularity and the diminished size 
of the carpal bones indicate the extent of the destructive process. The patient, the mother 
of the child (Figs. 10 and 11) with Pott's disease, died within a year, of tuberculosis of 
the lungs. 

sitive to pressure. At this stage repair may take place with but 
little ultimate change from the normal, but in many instances 
the bone is perforated and in part destroyed, the neighboring 
joint is involved, and the finger becomes stunted and distorted. 



478 ORTHOPEDIC SURGERY 

In 159 cases tabulated by Karewski, 1 the metacarpal bones 
were diseased in 65 instances; the phalanges in 57; the meta- 
tarsal bones in 29; the phalanges of the toes in 8. In a number 
of instances several of the bones and larger joints were involved 
also (159 cases in 135 patients). 

The disease is more common in the early years of life, 84 of 
the 135 patients being four years of age or less, 38 of these being 
less than two. 

Spina ventosa of the phalanges may be treated by rest and 
compression, and both splinting and compression may be assured 
by adhesive plaster strapping. If the joint is involved amputa- 
tion of the finger may be indicated, because of the distortion and 
loss of growth that may be expected. Tuberculous disease, 
limited to a single bone of the carpus or metacarpus, may be 
treated by operative removal of the disease. 

Periarthritis of the Shoulder. 

Under the title of scapulohumeral periarthritis, Duplay 2 in 
1872 described a painful affection of the shoulder induced by 
injury, dependent upon an inflammation of the bursa lying 
between the deltoid and supraspinatus and infraspinatus muscles 
and the coracoacromial ligament. But under this title are now 
included a number of affections that cause similar symptoms in 
which it would appear that the interior of the joint is not involved. 

Symptoms. — In a typical case of so-called periarthritis the 
patient complains of a dull pain about the joint and sensitiveness 
to pressure just below the acromion process or over the bicipital 
groove. The pain is increased by motion, particularly by abduc- 
tion or by rotation of the arm. In mild cases only extensive motion 
causes pain, but in most instances there is a constant sensation 
of discomfort which is increased to acute pain by sudden move- 
ments or jars. The part becomes sensitive to pressure, so that 
the patient avoids lying on the shoulder at night. In certain 
instances the pain may radiate down the arm, and there may be 
weakness and numbness of the fingers. Gradually the passive 
movements of the joint are diminished in range, and atrophy of 
the shoulder muscles appears. 

These symptoms usually pass as rheumatism, but there is no 
fever, no involvement of other joints, no swelling, and, as a rule, 

1 Chir. Krank. des Kindersalters, Berlin, 1894. 

2 Archiv. ge'ne'rale de m<5d., Paris, 1872. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 479 

no general sensitiveness to pressure, as is usual when the synovial 
membrane of the joint is affected. In certain instances the 
symptoms follow injury, or exposure to cold, or they appear 
without apparent cause. In one class of cases the symptoms may 
be due to an inflammation of the subdeltoid bursa, as in the cases 
originally described by Duplay; in others to a tenosynovitis of 
the biceps tendon. This is suggested by local sensitiveness at 
the bicipital groove, and by the creaking sensation at this point 
when the muscle is in use. Or the symptoms may be due to 
neuritis affecting the circumflex nerves, as suggested by Amidon. 1 
It is probable also that the nerves in the neighborhood of the 
joint may be secondarily implicated in an inflammation of bursse, 
or directly injured by the original traumatism, if such preceded 
the symptoms. It is also possible that the bursitis may have 
been a sequel of gonorrhoea or of other infectious disease. 

Treatment. — During the acute and painful stage the part should 
be kept at rest. Cautery may be applied and the joint should be 
enclosed in adhesive plaster strapping, and if the weight of the limb 
causes discomfort it should be supported. In certain instances 
tension on the sensitive part may be relaxed by supporting 
the arm in an attitude of abduction. When the acute symptoms 
have subsided passive movements, massage, and static electricity 
are of service. Voluntary exercises should be employed when 
they no longer aggravate the symptoms. In the cases of long 
standing in which motion is very much restricted, apparently 
by adhesions without the joint, passive movements under anaes- 
thesia to the extremes of the normal range are usually of benefit. 
In such cases it may be well to support the limb for a time in the 
abducted attitude to prevent the formation of the adhesions. 
Afterward passive motion, massage, and exercises must be em- 
ployed to prevent the return of the restriction. If these cases are 
treated carefully in the early stage, recovery is usually rapid, but 
if neglected the symptoms may persist indefinitely. 

Chronic Bursitis. 

Chronic bursitis at the shoulder-joint is comparatively infre- 
quent. The bursse most often involved are the coracoid, the 
subscapular, and the deltoid. Of these the last is the most often 
affected. Sixteen cases have been reported by Blauvelt, 2 and 

1 American Medico-Surgical Bulletin, March 21. 1896. 
- Beitrage zur klin. Chir., Bd. xxii. 



480 ORTHOPEDIC SURGERY. 

three others by Ehrhardt. 1 The enlarged bursa forms a fluctuat- 
ing swelling most noticeable on the anterior and outer aspect 
of the shoulder, the symptoms being discomfort, weakness, and 
limitation of motion of the arm. The disease is usually tuber- 
culous in character, and it should be treated by complete removal 
of the sac if possible. 

Sprain of the Wrist. 

This is a very common accident. The most effective treatment 
is the adhesive plaster strapping applied about the metacarpus, 
wrist, and lower half of the forearm. If the pain on motion is 
severe sufficient plaster is applied to splint the part and to limit 
movement to the point of comfort. If the injury is of a slighter 
grade the compression and support of a single layer of plaster is 
usually sufficient. This dressing prevents strain, and yet it allows 
a certain degree of functional use, which is the most effective 
means of restoring a joint to its normal condition by hastening 
the absorption of the effused material within and without the 
injured part. 

Chronic Sprain. — Persistent weakness and stiffness may follow 
treatment of a sprain by splints or when for any reason disuse of 
function has been long continued. In many instances, however, 
the sprain was in reality a fracture or displacement. All chronic 
sprains, therefore, should be examined by means of the x-ray in 
order that the presence or absence of more extensive injury may 
be determined. 

The treatment is similar to that of the acute sprain: protection 
from injury, and functional use to the extent of which the part is 
capable. With this, passive congestion, massage, hot air, and 
electricity or other form of local stimulation may be employed 
with advantage. The same treatment is indicated when the joint 
is stiff and painful as the result of rheumatism or other inflamma- 
tion, provided the stage of recovery has been reached. 

Acute Tenosynovitis. 

Tenosynovitis is common at the wrist-joint. It is usually 
induced by strain or overuse of a muscle or muscular group. 

Movements of the muscles that are involved cause discomfort, 
and there is usually local sensitiveness and a creaking sensation 

1 Archiv f. klin. Chir., Bd. lx. 



DISEASES OF ARTICULATIONS OF UPPER EXTREMITY 481 

on palpation over the affected tendon sheath. The adhesive 
plaster strapping, so applied as to exert compression and to 
prevent the motion that causes discomfort, is the most effective 
treatment. 

Chronic tenosynovitis, causing progressive enlargement of a 
tendon sheath, with accompanying symptoms of weakness and 
discomfort, is usually tuberculous in character. In such cases 
the diseased part should be promptly removed. If the disease is 
of long standing, extending into the palm of the hand it may 
be advisable to simply evacuate the contents, including the rice 
bodies, through an incision. An astringent solution may be 
injected, and after its removal the incision may be closed. Pres- 
sure is then applied, with the aim of securing partial adhesions 
of the apposed surfaces. 



:,\ 



CHAPTEK XIII. 

DEFORMITIES OF THE UPPER EXTREMITY. 

Congenital Dislocation of the Shoulder. 

This may occur in two forms, one in which there is actual 
misplacement before birth, and the other in which a dislocation 
is caused by violence at birth. In either case the displacement 
is almost always backward upon the dorsum of the scapula (sub- 
spinous). Thus the arm is abducted and rotated inward, and 
the head of the displaced bone may be felt in its abnormal position. 
Cases of congenital displacement in other directions are recorded, 
but these are so unusual as to be of little practical importance. 1 

True primary displacement of either variety is uncommon. 
Many of the reported cases were apparently subluxations secondary 
to the relaxation of the capsule of the joint and to the muscular 
atrophy caused by anterior poliomyelitis, or more often to the 
habitual malposition due to obstetrical paralysis (Fig. 306). 
According to Porter, 2 twenty-nine cases are recorded in literature, 
in at least half of which the diagnosis is doubtful. It is, of course 
apparent that both displacement and paralysis may be coincident 
and caused by injury at birth. 

Obstetrical Paralysis. 

Partial or complete paralysis of the muscles of the arm may 
be a result of difficult or protracted labor. It may be induced by 
direct pressure on the brachial plexus, but most often it is caused 
by traction on the body or the head, and by violent twists of the 
neck during delivery. In rare instances the paralysis may be 
bilateral. In some instances the nerve roots may be torn apart, 
in others the injury may be principally to the sheath causing 
hemorrhage, and in the process of repair scar tissue which presses 
upon the nerve elements. The muscles most often paralyzed are 
those supplied principally by the fifth and sixth cervical roots 
of the plexus — the deltoid, the biceps, and the supinators of the 

1 Scudder, American Journal of the Medical Sciences, February, 189S. 
- Transactions American Orthopedic Association, 1900, vol. xiii. 



DEFORMITIES OF THE UPPER EXTREMITY 



483 



forearm. Thus in most instances the arm hangs in an attitude of 
slight abduction and exaggerated pronation (Fig. 306). If the 
attitude is allowed to persist and if the paralysis is permanent, 
the head of the humerus, rotated backward beneath the atrophied 
deltoid muscle and finally fixed in the abnormal attitude by 
accommodative changes in the capsule and surrounding parts, 
simulates very closely in later years the true congenital dislocation 
of the shoulder (Fig. 307). 




Congenital dislocation of the left humerus, illustrating the characteristic attitude. 

Whether cases reported as congenital displacement of the humerus 
are secondary to paralysis or not, it is evident that all cases of 
obstetrical paralysis should be carefully examined with regard 
to a complicating dislocation, and that the secondary deformity 
induced by paralysis should be prevented. 

Treatment. — During the first month after birth the shoulder 
of the paralyzed arm is often somewhat swollen, and motion may 



484 



ORTHOPEDIC SURGERY 



cause pain. In such cases rest is indicated. The arm should be 
placed against the side, and the hand, with the fingers extended, 
should be supported on the chest beneath the clothing. When 
the primary sensitiveness has subsided, each of the joints of the 
extremity should be moved systematically to the limit of the normal 
range of motion several times in a day. Particular care should be 
exercised in supinating the forearm and extending the wrist and 
fingers, if they are involved in the paralysis. The muscles should 

be massaged, and the arm should 
be supported by a sling, or other- 
wise, in proper position. Recov- 
er} 7 may be complete, although 
it is often delayed for many 
months. As a rule, traces of the 
injury are evident in atrophy of 
certain muscles, particularly of 
the deltoid, and a certain weak- 
ness of the arm persists, even 
though no actual paralysis re- 
mains. 

In many instances recovery is 
but partial, the arm is weak, cer- 
tain muscles are paralyzed, and 
there is much restriction of move- 
ment at the shoulder. The growth 
of the member is retarded, and 
as has been mentioned, the at- 
titude is that characteristic of 
posterior dislocation. Not in- 
frequently, although the actual 
paralysis is slight, the disability 
is extreme because of the dis- 
placement. The essential in 
treatment, therefore, is to replace the head of the humerus in the 
proper position. This applies to the congenital as well as to the 
acquired disability. 

Reduction of Deformity. — The principles of the treatment of 
the displaced humerus are to reduce the deformity, to fix the part 
for a time sufficient to prevent relapse, to restore function as far 
as may be by systematic passive motion, and by exercise. 

The child having been anaesthetized, is brought to the edge 
of the table. The shoulder is grasped firmly with one hand in 




The characteristic attitude of 
paralysis in infancy. 



DEFORMITIES OF THE UPPER EXTREMITY 485 

order to restrain the movements of the scapula, and with the other 
the arm is drawn upward and backward over the fulcrum of 
the thumb, which lies behind the joint. This, the so-called pump- 
handle movement, alternately relaxing and stretching the contracted 
parts, is carried out over and over again with slowly increasing 
force, the aim being to force the head of the bone forward, and 
thus to overcome the resistance of the anterior part of the capsule. 




The deformity of obstetrical paralysis in adolescence. 

When this has been accomplished, there is a distinct depression 
behind, and the head of the humerus projects in front, at a point 
below its proper position. 

One then attempts to overcome the abduction and to force the head 
upward by changing the grasp on the scapula and using the thumb 
in the axilla as a fulcrum. When the arm can be carried across 
the chest to the normal degree of adduction, the final, and often most 



486 ORTHOPEDIC SURGERY 

difficult, part of the process, namely, to stretch the tissues suffi- 
ciently to permit the proper degree of outward rotation, is under- 
taken. This is best accomplished by flexing the forearm and using 
this to exert leverage on the humerus, care being taken, of course, 
to avoid the danger of fracture. When the head of the bone has 
been replaced, it will often be noted that the tension on the anterior 
tissues causes flexion of the forearm; this must be overcome in the 
same manner, and, finally, the limitation to complete supination. 
The extremity is then fixed in the over-corrected attitude by means 
of a plaster bandage which includes the thorax. That is, the 
arm is drawn backward so that the head of the humerus is made 
prominent anteriorly, the forearm is flexed and turned outward to 
the frontal plane, while the hand is placed in extreme supination, 
the arm lying against the lateral thoracic wall. 

In the very resistant cases it is impracticable to complete the 
operation at one sitting. When, therefore, as much force has been 
exercised as seems wise, a plaster bandage is applied, and after 
an interval of two weeks the further correction is undertaken. 
This, however, is not often necessary. In the treatment of older 
subjects the forcible manipulation may be preceded or supple- 
mented by division of resistant parts. 

As has been stated when the head of the bone is forced forward 
a distinct depression and evident relaxation of the tissues is noted 
on the posterior aspect of the joint. The object of the fixation is 
to allow the contraction of the posterior wall of the capsule and 
the obliteration of the old articulation, consequently, the part 
must be fixed for a period of at least three months. When the 
plaster bandage is removed, the after-treatment is of great impor- 
tance. This consists of daily passive forcible movements to the 
extreme limits in the directions formerly restricted; namely, outward 
rotation, backward extension, and eventually abduction of the 
humerus and supination and extension of the forearm. For in all 
these cases there is a strong tendency to a return in some degree 
to the original posture. When motion has become fairly free, 
the disabled member must be regularly exercised and re-educated 
in functional use. Under this treatment the weakened and almost 
completely atrophied muscles usually gain surprisingly in power 
and ability, and the longer it is continued the better will be the 
final result. If the deltoid muscle is completely paralyzed, one 
cannot expect independent movement at the shoulder, and the aim 
should be to gain fibrous ankylosis in the attitude of outward 
rotation in order to permit supination of the forearm. 



DEFORMITIES OF THE UPPER EXTREMITY 487 



Repair of Obstetrical Injury to the Brachial Plexus. 

It is evident that if repair of the ruptured or otherwise injured 
cords of the brachial plexus does not take place, recovery is impos- 
sible. If then the paralysis persists, direct operative intervention 
may be indicated in selected cases. 

Kennedy 1 has operated on a number of cases for this purpose, 
in one instance as early as two months after birth. 

His method is as follows: 

An incision from above downward is made along the posterior 
border of the sternomastoid to the junction of the middle and outer 
thirds of the clavicle. The deep fascia is divided, the omohyoid 
is depressed, and the scaleni muscles are exposed between the 
anterior and middle of which passes the plexus with the sub- 
clavian artery below; the uppermost cords of the plexus are usually 
involved. The scar tissue is cut away and the freshened surfaces 
are then united. The wound is closed, the head is inclined 
toward the shoulder, and a plaster support is applied. Several 
encouraging results of this operation have been reported. 

If the deformity is of long standing, operations on the injured 
nerves of somewhat doubtful utility at best can have no influence 
on the disability unless distortions and contractions have been 
overcome in the manner already described. 

Recurrent Dislocation of the Shoulder. 

Recurrent dislocation of the shoulder is in most instances a 
sequel of traumatic dislocation. The cause of the instability is 
usually laxity of the capsular ligament and weakness of the sup- 
porting muscles, the result, it may be, of too early use of the arm 
after the accident. In rare instances greater derangement of the 
joint caused by fracture of one or other of the articulating sur- 
faces, rupture or displacement of ligaments or muscles, or per- 
manent paralysis of the deltoid muscle may be present. 

The displacement, which may be partial or complete, recurs at 
intervals and is a very serious disability. 

Treatment. — If the patient is seen immediately after a displace- 
ment and if the dislocation has recurred but a few times and at 
long intervals, it may be inferred that the disability is the result 
of simple laxity of the capsule and of muscular weakness. In 

1 Brit. Med. Jour., 1903, p. 298. 



488 



ORTHOPEDIC SURGERY 



such cases a period of fixation followed by massage and exer- 
cise of the atrophied muscles may result in cure. The patient 
should be carefully questioned as to the particular movements of 
the arm that are likely to cause the displacement, which is, as a 
rule, forward beneath the coracoid process. Most often elevation 
and abduction seem to be the predisposing movements that should 
be restrained. A simple and often an effective means of treat- 
ment is the application of a shoulder-cap of canvas that fits closely 




ie lorearms. 



about the shoulder and upper arm. This is held in place by bands 
crossing the body and buckled beneath the other arm; from the 
lower border of the cap one or more bands pass downward and 
are attached with the braces to the trousers, so that elevation of 
the arm is restrained, before the point of instability is reached. 
Operative Treatment. — If these milder measures are ineffective, 
an operation to reduce the size of the lax capsule may be per- 
formed. The arm being slightly abducted, an incision is made 



DEFORMITIES OF THE UPPER EXTREMITY 489 

from the coracoid process downward and outward along the line 
of the cephalic vein to a point below the upper border of the tendin- 
ous insertion of the pectoralis major. The deltoid and the pec- 
toralis major are separated, exposing in the upper border of the 
wound the coracobrachialis, and in the lower angle the upper part 
of the insertion of the pectoralis major muscles. The upper 
three-fourths of this insertion is divided in order to expose the 
head and neck of the bone. The humerus is then rotated outward 
and a portion of the insertion of the subseapularis muscle, 
stretched over the head of the humerus, is divided. The capsule 
is thus laid bare, and a sufficient section is removed to overcome 
the laxity. The wound is then closed. 

Similar operations in which the lax capsule was overlapped 
and sutured without opening it have been performed, by Ricard 
in 1892 and by Steinthal in 1895. 1 

Congenital Deformities of the Elbow. 

Congenital displacement of the ulna is one of the rarest of 
deformities. The displacement is usually incomplete, and it is 
associated with laxity of the ligaments. 

Congenital displacement of the radius is much more common, 
53 cases having been reported. 2 

In many instances the head of the radius is displaced backward ; 
thus the forearm is pronated and extension is usually limited. 
In some cases a certain range of pronation and supination is 
present but in others the two bones are joined by bony growth 
(Fig. 308). Excision of the head of the radius, separation of the 
bones, fixation for a time in the attitude of supination followed by 
passive motion, and exercises would be indicated in operative 
treatment. 

Cubitus Valgus, Cubitus Varus. 

Cubitus valgus, in which the forearm is abducted at the elbow, 
and cubitus varus, in which it is inclined in the other direction, 
are occasionally seen as congenital deformities. They are, in 
most instances, associated with laxity of the ligaments. 

Similar deformities are not uncommon during the progressive 
stage of rhachitis, but they usually disappear after the erect 
attitude is assumed, when the arms are relieved of the strain of 
supporting the body in the sitting posture. 

1 Burrell and Lovett, American Journal of the Medical Sciences, August, 1897. 

2 Blodgett, Amer. Journ. Orth. Surg., January, 1906. 



490 ORTHOPEDIC SURGERY 

The forearm forms an angle with the upper arm, opening 
outward when the limb is extended at about 173 degrees in males 
and 167 degrees in females. 1 This is sometimes called the "carry- 
ing" angle, because the hand is held at some distance from the 
body while the arm is in contact with the trunk. What may be 
called normal cubitus valgus is common among women, and in 
certain instances it may be exaggerated to deformity. Acquired 
cubitus varus is usually the result of direct injury. Both de- 
formities may be treated by osteotomy of the humerus just above 
the articulation after the method used to correct similar de- 
formity at the knee. If in addition to the lateral deformity motion 
is restricted by displaced fragments of bone or by exuberent 
callus it is advisable to open the joint for the purpose of removing 
the obstructions. After operation for the correction of lateral 
deformity the arm should be fixed by a plaster bandage which 
should include the hand in full extension. 




"Spontaneous subluxation of the wrist." 

Subluxation of the Wrist. 

A peculiar displacement of the hand forward and usually toward 
the radial side, described by Madelung 2 as "spontaneous subluxa- 
tion," is sometimes seen in young subjects whose occupation may 
require constant use of the flexors of the hand and fingers. In 
these cases the lower extremity of the ulnar is displaced toward 
the dorsum of the hand; there is abnormal separation of the two 
bones of the forearm from one another at the wrist, and in many 
instances the lower extremity of the radius is bent forward. As 
a consequence the wrist is enlarged, the ligaments are relaxed, 

1 Potter, Journal of Anatomy and Physiology, vol. xxix. p. 488. 

2 Archiv f. klin. Chir., Bd. xxiii. 



DEFORMITIES OF THE UPPER EXTREMITY 491 

and dorsal flexion of the hand is restricted. The symptoms, 
aside from the deformity, are weakness and sensations of discom- 
fort about the dorsum of the wrist. 

Etiology. — The predisposing causes of the affection are, appar- 
ently, relaxation of the ligaments, and, possibly, slight pre-existing 
rhachitic deformity of the same character. The exciting causes 
are occupation or injury. The slight forward bending of the 
lower extremity of the radius is due, apparently, to irregularity 
in growth at the epiphyseal junction. 

Treatment. — The treatment is rest, massage, forcible manipu- 
lation in the direction of extension, and a support of leather or 
other material to hold the hand in the extended position. In 
more extreme cases the deformity of the radius may be overcome 
by osteotomy. 

Congenital [Deformities at the Wrist. 

Simple congenital dislocation at the wrist is extremely rare. 
Displacement of the wrist and hand is usually associated with 
defective development of the bones of the arm, and the deformity 
is usually classed as club-hand. 

Club-hand. 

Congenital distortions of the hand may be divided into four 
primary varieties, according to the direction in which the hand is 
turned, viz.: 

1. Forward or palmar. 

2. Backward or dorsal. 

3. Lateral to the radial side — radial. 

4. Lateral to the ulnar side — ulnar. 

Lateral and anteroposterior distortions occur also in combina- 
tion. 

Etiology. — There are two distinct varieties of club-hand: 

1. In which there is simple distortion caused apparently by 
abnormal restraint and pressure in utero. In certain cases of 
this class there may be limited motion at both the shoulder and 
elbow-joints and defective muscular development, apparently 
dependent upon long-continued fixation. 

2. In which the deformity is associated with defective develop- 
ment of the radius or ulna and often with congenital abnormali- 
ties of other parts. 



492 



ORTHOPEDIC SURGERY 



In the palmar and dorsal distortions the bones of the arm are 
usually normal. The lateral deviations of the hand are often 
complicated by defective formation of the radius or ulna, and as 
in talipes due to absence of the tibia or fibula the hand may be 
malformed also. 

Deficient formation of the radius with corresponding distortion 
is the most common. Of this 114 cases are recorded. In 56 cases 
it was stated that the deformity was unilateral, in 46 bilateral. 
In 44 cases the radius was absent; in 12 cases a part was present; 
60 per cent, of the patients were males. 1 



K 



m 



Club-hands and club-feet. 



The most important form of club-hand is, then, that due to 
absence or to defective formation of the radius. As in talipes 
valgus due to absence of the fibula, the tibia is short and often 
bent sharply forward, so in this form of club-hand the ulna is 
usually short and bent inward. The hand may be perfect in 
formation, but, as a rule, the thumb is absent or rudimentary, and 
other adjoining bones, together with the corresponding ligaments 
and muscles, may be absent also (Fig. 311). 

The hand occupies practically a right-angled relation to the 



Antonelli, Zeits. f. orth. Chir., 1905, Bd. xiv. 



DEFORMITIES OF THE UPPER EXTREMITY 493 

ulna, and as this bone is usually bent inward as well, the direction 
of the hand is often reversed and is parallel to the forearm. As 
a rule, the hand is also somewhat bent forward, so that the defor- 
mity might be described as radio palmar (Fig. 312). 

Treatment.— In those forms of club-hand in which the struc- 
ture is normal the deformity may be overcome, as a rule, by manipu- 
lation, and support by the plaster bandage or otherwise, as de- 
scribed in the treatment of talipes. Massage and muscle training 
are required in the after-treatment. If the deformity is complicated 




Congenital absence of radius and the bones of the thumb. (Weigel.) 

by defective muscular development and limited joint motion 
massage and passhse manipulation may be required for years. 
Complete recovery is unusual. 

In slighter cases of radial club-hand, due to defective develop- 
ment, it may be possible by manipulation and tenotomy to replace 
the hand in its normal position, but this is unusual. As a rule, 
an operation on the ulna will be necessary, together with divi- 
sion of the contracted tissues. Sayre 1 removed a portion of the 
carpus and implanted the head of the ulna at the point of resec- 
tion. McCurdy 2 sawed through the ulna, leaving the extremity 

1 Transactions American Orthopedic Association, vol. vi. 

2 Ibid., vol. viii. 



494 



OB THOPEDIC S UB GEB Y 



in relation to the carpus and sutured the proximal fragment and 
the semilunar bone to one another. Thomson 1 replaced the hand 
by subcutaneous tenotomy and by the removal of a cuneiform 
form section of bone from the lower end of the ulna. 

The operation of splitting the ulna into an ulnar and radial 
portion and implanting the carpus between the two has been 
performed by Bardenheuer. 2 The 
immediate effect of the various 
operative procedures was favorable, 
but no final results have been re- 
ported. 

In any event some form of appar- 
atus must be used during childhood 
at least, to support the hand, 
whether the operation has been suc- 
cessful or not ; and at best the arm 
will be short and the thumbless hand 
weak as compared with its fellow. 

Congenital Contraction of 
the Fingers. 

The most common form of con- 
genital contraction and one that is 
sometimes hereditary is that of the 
little finger (hammer finger) of one 
or both hands. This is semiflexed 
and extension is checked by what 
appears to be a congenital shorten- 
ing of all the soft parts on the flexor 
side. In other instances several 
fingers may be similarly affected. 

Treatment. — If treatment by ma- 
nipulation and splinting is begun 
early the deformity may be over- 
come by lengthening the contracted 
tissue. In later life the prospect of perfect cure by any method of 
treatment is slight, because of the strong tendency to recontrac- 
tion after the finger has been straightened. 




Congenital club-hands, showing the 
short and deformed forearms, also 
bow-legs. (Gibney.) 



Transactions American Orthopedic Association, vol. ix. 
Verhand. der deutsch. Gesells. f. Chir., 23 Kong., 1894. 



DEFORMITIES OF THE UPPER EXTREMITY 495 

Webbed Fingers. 

In the most common form of this deformity two or more fingers 
are joined by skin and fibrous tissue to the first phalangeal joints, 
but sometimes throughout the entire length of the fingers. 

In other instances the web may be thicker, containing muscular 
fibres from the apposed parts, and, occasionally, the bones of the 
two fingers may be joined to one another, even to the finger-nails. 

Etiology. — The cause of the deformity is arrest of develop- 
ment before the fingers have been separated from one another; 
thus the thumb, which is differentiated from the other parts of 
the hand as early as the seventy-fifth day of intrauterine life, is 
rarely involved, as compared with the fingers, which are separated 
from one another at a later period. 

Treatment. — In all but the extreme grades of deformity the 
fingers may be separated from one another, operative treatment 
being conducted according to the rules of plastic surgery. 

Congenital Displacements of the Phalanges and Distortions 
of the Fingers. 

These deformities are not particularly uncommon. They should 
be treated by manipulation and by splinting at as early a period 
as is practicable. Other congenital deformities and malformations 
of the hand do not call for extended comment. 

Trigger Finger. 

Synonyms. — Jerking finger, snapping finger. 

This affection was first described by Nekton under the title 
"Doigt a Ressort." On extending the closed hand one finger 
remains flexed. If the flexidn is overcome by greater muscular 
effort or by passive force the finger flies back to complete extension 
with a sudden snap or jerk; hence the name. In well-marked 
cases the same difficulty and the subsequent snap is experienced 
in flexing the finger. The middle and ring fingers are more 
often affected, but sometimes the thumb or the fifth finger may 
be involved. 

The patient usually complains somewhat of stiffness and pain 
in the finger, but the interference with its function is the prin- 
cipal symptom. 

Etiology. — The cause of the disability is interference with the 
motion of the tendon in its fibrous sheath, either because of a 



496 ORTHOPEDIC SURGERY 

reduction of its calibre due to injury or inflammation, or to an 
enlargement or irregularity of the tendon itself. In most instances 
the obstruction appears to be in the neighborhood of the meta- 
tarsophalangeal joint. 1 

The duration of the affection is indefinite. 

Treatment. — If the obstruction appears to be of inflammatory 
or traumatic origin it may be treated by splinting and later by 
massage. In confirmed cases the tendon and the sheath may be 
explored in the hope of finding and removing the obstruction. 2 

Mallet Finger. 

Synonym.— Drop-finger. 

This is caused usually by a blow upon the terminal phalanx, 
which ruptures or weakens the attachment of the extensor tendon 
at the base of the phalanx so that it is habitually flexed some- 
times nearly to a right angle. 

The treatment must be by incision and re-attachment of the 
tendon to the periosteum. 

"Baseball finger" is the reverse displacement of the terminal 
phalanx, which is dislocated backward, forming a bayonet-like 
deformity. There is often, in addition, injury of the base of the 
phalanx that causes subsequent irregular hypertrophy. 

If reposition is impossible open incision may be employed to 
correct the deformity. 

Dupuytren's Contraction. 

Dupuytren's contraction is a deformity of the hand caused by 
contraction of a part of the palmar fascia and of its prolongations 
to one or more of the fingers. The fingers are flexed as a conse- 
quence to a greater or less degree, and in advanced cases they 
may be drawn to close contact with the palm. The ring finger 
is most often primarily affected, but, as a rule, two or more fingers 
are somewhat involved in the contraction. 

In a large proportion of the cases both hands are affected, 
but not as a rule simultaneously, the contraction beginning in the 
second hand several years after the deformity in the first. 

Pathology. — The characteristics of the deformity are explained 
by the anatomy of the palmar fascia. This consists of a strong 

1 Marches, Deutsch Zeits. f. Chir., Bd. lxxix., p. 364. 

2 The bibliography ia large. More recent articles are those of Jamin, Cent. f. Chir., June 
6, 1896, who reports thirty-one cases, and A. Necker, Beitriige zur klin. Chir., B. x. p. 469. 



DEFORMITIES OF THE UPPER EXTREMITY 497 

central portion, and two thinner lateral parts that cover the mus- 
cles of the thumb and little finger. It is made up of longitudinal 
fibres continuous with the tendon of the palmaris longus, and 
the annular ligaments. It divides into four processes that are 
attached to the digital sheaths, to the integument at the clefts 
of the fingers, and to the superficial transverse ligament. Pro- 
longations of the fascia pass along the lateral aspect of the fingers 
and are attached to the periosteum and to the tendon sheaths of 
the first and second phalanges. 

The cause of the contraction appears to be a chronic plastic 
inflammation of a part of the fascia, which becomes hypertrophied 
and finally contracts, drawing the finger toward the palm in the 
manner described. 

Etiology. — The etiology is uncertain. 

The contraction is much more common in men than in women, 
and it is practically confined to middle and later life. It is ciaimed 
that the deformity is more common among those who are subject 
to gout or rheumatism. It appears, also, to be an hereditary 
affection in certain instances. Injury or irritation of the palmar 
tissues, incident to certain occupations, would seem to explain 
the disproportionate liability of the sexes to the affection. 

Symptoms. — The first symptom is usually the deformity; the 
patient finds it impossible to completely extend one or more of 
the fingers; the tissues about the base of the finger seem stiff, 
and when it is forcibly extended a hard, elevated cord may be 
felt extending from about the centre of the palm to the second 
phalanx, most prominent at the metacarpophalangeal articulation. 

To this the skin is adherent, and as the contraction increases 
it is thrown into elevated ridges. Later other bands appear if 
the contraction affects, as it usually does, other portions of the 
fascia. In many instances no pain is experienced unless the con- 
tracted fascia is forcibly stretched or is passed upon. In other cases 
complaint is made of neuralgic pain in the hand and even in the 
arm and back. Occasionally the first symptom to attract atten- 
tion may be a sensitive nodule in the skin at the base of the finger. 

The contraction usually increases slowly until the finger that 
is most affected is drawn to the palm. 

Treatment. — The deformity may be overcome in part by mul- 
tiple division of the contracted bands from the finger to the palm, 
but complete removal of the contracted fascia is preferable if it 
be possible. The finger is then supported in an attitude of slight 
flexion until the circulation is adjusted to the new position. 

32 



CHAPTER XIV. 

CONGENITAL AND ACQUIRED AFFECTIONS LEADING TO 
GENERAL DISTORTIONS. 

Rhachitis. 

Syno.nym.— Rickets . 

Rhachitis is a constitutional disease of infancy caused by de- 
fective nutrition, of which the most marked effect is distortion 
of the bones. 

Etiology. — The predisposing cause is constitutional weakness. 
This may be inherited or it may be the direct effect of illness, 
but most often it is the result of improper hygienic surroundings, 
particularly lack of sunlight, damp rooms, overcrowding, and defec- 
tive ventilation. The direct cause of the disease is improper 
nourishment. In most instances this is due to the substitution 
of artificial food for the mother's milk, in others to improper diet 
after the infant is weaned; in rare cases it may be the result of 
prolonged lactation, or it may be caused by the defective quality 
of the mother's milk. The disease, therefore, begins usually 
between the ages of six and eighteen months, although it is by 
no means confined to these limits. 1 In most instances improper 
surroundings and improper nourishment are combined in the 
causation of the disease; thus rhachitis is relatively common in 
large cities. At the Hospital for Ruptured and Crippled the 
most extreme cases are observed among the Italian and the colored 
children. The former are usually nursed, but are improperly 
fed after weaning, while the latter, if nursed at all, are usually 
allowed a mixed diet even during the early months of life. 

1 According to Baginsky the age of onset in 623 cases was as follows: 

Males. Females. Total. 

3 — 6 months 35 8 43 

6—12 " 101 72 173 

1 — IK years 115 105 220 

W % — 2 64 49 113 

2 — 2% " 18 24 42 

2%— 3 9 12 21 

3 — 4" 2 5 7 

4 — 13 4 

344 275 623 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 499 

Pathology. — The manifestations of a disease dependent upon 
impaired nutrition are, of course, general in character. In rha- 
chitis there is a mild degree of anaemia, and a general weakness 
and relaxation of the voluntary and involuntary muscles. As 
a result the circulation is impaired and the power of assimila- 
tion is diminished; thus congestion and enlargement of the internal 
organs, intestinal catarrh, bronchitis, and the like are common 
accompaniments of the disease. The most marked and char- 
acteristic changes are found in the bones; these consist in a dimi- 
nution of the earthy substances and in overgrowth of osteoid tissue. 

"The essential features of the morbid processes are, first, an 
exaggeration of the processes immediately preparatory to the 
development of true bone; secondly an imperfect conversion of 
this preparatory tissue into true bone; and thirdly, a great irregu- 
larity of the whole process." (Erichsen.) 

On section of rhachitic bone it will be noted that the perios- 
teum is increased in thickness, and is more or less adherent to 
the underlying softened and spongy tissue. The medullary canal 
is enlarged, and its contents are abnormally vascular. The 
epiphyseal cartilage, normally a thin, bluish line, is much increased 
in thickness. It appears to be swollen and infiltrated, and it has 
lost its former translucency. Microscopic examination at this 
point, where growth is most active, shows marked irregularity 
in size and shape of the columns of cartilage cells; the zone of 
calcification is lacking or is ill-defined, and masses of cartilage 
cells are found unchanged in what should be the area of true 
bone. The same irregularity of line and shape is observed in 
the medullary spaces of the newly formed osteoid tissue. 

As a direct result of the changes that- have been described, the 
epiphyseal junctions are enlarged and the shafts of the bones are 
thickened by the formation of osteoid tissue beneath the perios- 
teum. The indirect effects of the disease, and of the weakness 
that it causes are deformities, the nature of which will be indi- 
cated under the heading of symptoms. The stage of weakness 
is followed by that of repair, which sometimes goes on with 
great rapidity; the softened bones become abnormally hard, "ebur- 
nated," and premature solidification at the epiphyseal junctions 
may be one of the remote results of the disease that accounts 
in part for the dwarfing of the stature, observed as one of the 
final results of severe rhachitis. 

Symptoms. — As the disease is the effect of imperfect assimi- 
lation its more pronounced symptoms are preceded by those of 



500 OR THOPEDIC SURGERY 

indigestion, such as flatulence, constipation, and the like. Pro- 
fuse perspiration, especially about the head, and restlessness at 
night are common symptoms. Teething is often delayed or is 
irregular. The infant is slow in its movements, and makes little 
effort to stand or to walk at the usual time, and if the disease is 
active the affected parts may be sensitive to pressure. 

Deformities. — The deformities are in part due to the direct effect 
of the disease. One of the earliest and most constant evidences 
of rhachitis is the enlargement about the epiphyses, an enlarge- 
ment caused in part by the direct hypertrophy and in part by 
pressure upon the softened tissues. The enlargements at the 
junctions of the ribs and the costal cartilages, the rhachitic rosary, 
and at the wrists and ankles, double joints, are almost invariably 
present in well-marked cases. The more general distortions are 
in part the effect of atmospheric pressure, in part the effect of 
the force of gravity and habitual postures, and in some instances 
muscular action or injury may deform the softened bones. These 
deformities differ greatly according to the time of onset of the 
disease, and with its duration and severity. The head may be 
long and oblong in shape, or rectangular, caput quadratum, and 
it sometimes presents prominences in the frontal and parietal 
regions due to thickening of the bone, and on the posterior aspsct 
depressed and softened areas, craniotabes. The fontanelles are 
abnormally large, and they may remain open long after the usual 
time of closure. 

The thorax is compressed from side to side, the compression 
being most marked in the middle region, where the ribs have the 
longest cartilages and the least direct support. As secondary 
results the back of the thorax is flattened and the sternum is thrust 
forward, forming the pigeon breast. The lower ribs are everted 
to accommodate the- distended abdomen, potbelly. In well- 
marked cases the rhachitic chest presents two distinct grooves: 
one transverse in the axillary line, Harrison's groove, and the 
other passing upward by the side of the rhachitic rosary. These 
deformities are in great degree caused by atmospheric pressure, 
but they are increased if the child assumes the sitting posture 
habitually. In this attitude the body is inclined forward, the 
clavicles are distorted, and the spine is bent into a more or less 
rigid posterior curve, most marked in the lower dorsal and lumbar 
regions, the rhachitic kyphosis. Less often there may be a lateral 
deviation or scoliosis. 

The arms may be distorted by the efforts of the child to support 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 501 

the body in the sitting posture, or by active exertion, as in creeping 
(Fig. 313). Occasionally the deformities may be localized at 
the elbows, and sufficiently marked to merit the name cubitus 
varus or valgus, corresponding to genu valgum or varum; or 
the principal distortion may be a dorsal convexity of the lower 
extremity of the radius. 

Spindle-shaped phalanges are sometimes noted among the early 
signs of rhachitis in young children. 1 




General rhachitic deformities, showing distortions of the arms and legs induced by posture. 

The bones of the lower extremities are often distorted, primarily 
by the habitual postures assumed in sitting or creeping, and these 
deformities are usually exaggerated when the erect attitude is 
assumed. In some instances it would appear that the femoral 
necks are twisted backward somewhat; this distortion induced 
apparently by the cross-legged attitude of sitting may explain in 
part the limitation of inward rotation that is sometimes observed 
in rhachitic children. Depression of the femoral neck (coxa 
vara) may be present also, although this deformity does not, 

1 Neurath, Wien Klin., v. xl., N. 1617. 



502 OB THOPEDIC SURGERY 

as a rule, attract attention until a much later period of life. The 
changes in the pelvis are of special interest to the obstetrician. 
These are essentially an increase in the sacrovertebral prominence 
due to the forward and downward displacement of the sacrum, 
an abnormal expansion of the ilia, caused by pressure of the 
abdominal contents, and, in some instances, a decrease of the 
lateral diameter, an effect of the pressure of the femora upon 
the yielding bone. 

In the milder type of rhachitis in older children who walk, the 
deformities are often confined to the trunk and lower extremities. 
In such cases, in addition to the changes in the bones, there is 
usually a prominent abdomen and increased lordosis, combined 
with slight habitual flexion of the thighs and lower legs, the rhachitic 
attitude. 

If the disease is of sudden onset and is severe and general in 
its manifestations it may be accompanied by pain, by sensitive- 
ness of the affected bones, and by such weakness of the lower 
extremities as may simulate paralysis, rhachitic 'pseudoparalysis. 
It is probable, however, that the cases in which the pain is extreme, 
"acute rhachitis," are, in reality, scurvy or scurvy and rhachitis 
combined, scurvy rickets so-called. 

Rhachitis, as described, is the type ordinarily seen in hospital 
practice, and its manifestations are unmistakable. In its milder 
form it is not particularly uncommon among the children of the 
well-to-do, whose hygienic surroundings are good. In such 
cases the most marked symptom is weakness. The child is 
often fat and well developed, although, as a rule, pale. The 
abdomen is somewhat enlarged and slight prominences at the 
epiphyseal junctions, particularly at the wrists, may be made out. 
The legs appear small in proportion to the body, and the liga- 
ments are lax, so that if the child stands the feet are flat and 
assume the attitude of valgus. In this class, in which the child 
is said to have weak ankles, knock-knee is common. 

The most common symptom of rhachitis of the mild type is the 
failure of the child to attempt to walk at the usual time, about 
sixteen months. A child of normal intelligence who is not ill and 
who has not suffered from exhausting disease and does not walk at 
two years of age is probably rhachitic. 

Prognosis. — The duration of the progressive stage of rhachitis 
depends, of course, upon the age of the patient and upon the treat- 
ment. In cases that are untreated and in which the predisposing 
causes continue, the period of repair may be delayed for several 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 503 

years or longer, as shown by the fact that the child makes little 
effort to stand. But, in most instances, the rhachitic child begins 
to walk at some time during the third year, and at this time the 
deformities of the lower extremity, knock-knee, bow-leg, flat-foot, 
and the like usually develop or become aggravated, while those 
of the upper extremity may become less noticeable. 

The deformities of rhachitis tend to disappear or to become 
less marked with growth; the concavities of the distorted shafts 
are filled by accretions of periosteal bone, which is again absorbed 
from the interior as the medullary canal straightens itself. The 
thickened diaphyses and enlarged epiphyses become more sym- 
metrical under the influences of rapid growth and increased func- 
tional activity, but traces of severe rhachitis always remain, and 
many of the more noticeable and permanent distortions of the 
trunk and of the lower extremities are due to this cause. 

The prognosis as to the outgrowth of rhachitic deformities 
depends upon the duration and the severity of the disease and 
upon the function of the deformed part. Rhachitic distortions 
of the arms almost always disappear. The rhachitic chest is 
rarely seen in the adolescent or adult. The rhachitic kyphosis 
is corrected or modified when the erect posture is assumed, but 
rhachitic scoliosis, on the other hand, usually increases with the 
growth. Distortions of the lower extremities may occasionally 
entirely disappear, and in most cases they are less marked in the 
adult than in the child. Stunting of the growth is a constant 
effect of severe and prolonged rhachitis; it depends in part upon 
the arrest of development during the active stage of disease and 
in part upon the changes in the bones that cause premature con- 
solidation at the epiphyses. 

Treatment. — The treatment of rhachitis consists essentially 
in a reversal of the conditions under which it developed. It 
is therefore dietetic, hygienic, and medicinal. Deformity, the 
effect of the disease, may be prevented by guarding the weakened 
bones from overstrain, and it may be remedied, if it be present, 
by manipulation or by mechanical or by operative treatment. 

The more detailed treatment of rhachitis may be found in 
works on Pediatrics. In general, the diet in the cases developing 
in early infancy should be of milk, especially modified according 
to the need of the patient. At a later time, corresponding to the 
normal period of weaning, the diet should be largely animal, to 
the exclusion of starchy food, cream and fresh butter being espe- 
cially valuable. 



504 ORTHOPEDIC SURGERY 

The patient, protected by proper woollen underclothing, should 
pass as much time as possible in the open air, and should sleep 
in a well-ventilated room. Daily salt baths are recommended 
for older children, and regular massage of the extremities and of 
the abdomen should be employed. Medicinal treatment is of 
secondary importance. The bowels should be regulated and 
digestion should be aided by proper remedies. For anaemia, 
which is usually present, the syrup of the iodide of iron is of 
value; cod-liver oil serves both as a food and medicine, when it 
is readily assimilated. It is unlikely that any drug has a very 
direct influence on the disease. Phosphorus in doses of -jifo *° 
T ^ T of a grain is often given, and is supposed to lessen the abnor- 
mal congestion of the bones, while the deficiency of lime salts 
may be supplied possibly by the administration of lime in some 
form, the syrup of the lactophosphate of lime being a favorite 
prescription. 

The prevention of deformity, other than by the means already 
enumerated, consists in preventing habitual postures that predis- 
pose to deformity, and in daily massage and manipulative cor- 
rection of incipient distortions. Young infants and those whose 
bones are especially vulnerable should spend much of the time 
in the reclining posture. The Bradford frame or similar appli- 
ance is especially useful in the treatment of this class of cases. 
The treatment of the more advanced deformities, by support or 
by operation, is described elsewhere. 

"Late Rickets." 

Late rickets is, as the name implies, an affection presenting 
all the characteristics of the common infantile form. This, in 
rare instances, appears in later childhood or even in adolescence; 
in some cases the affection appears to be a continuation or recru- 
descence of the infantile form; in others no history of a preced- 
ing affection can be obtained. 1 

By many writers the term late rickets is improperly used to 
explain the deformities of adolescence, genu valgum, coxa vara, 
and the like, although none of the distinctive signs of the affec- 
tion may be present. Local rickets is less objectionable as applied 
to the same class of cases. 

1 Drewitt, Transactions of the London Pathological Society, 1881, vol. xxxii. Clutton, 
St. Thomas' Hospital Reports, 1884. vol xiv. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 505 

Chondrody strophia . 

Synonyms. — Foetal rhaehitis, achondroplasia. 

Cases that present the signs of what appears to be severe general 
rhaehitis at birth are not especially uncommon. The trunk is 
disproportionately long as compared to the stunted limbs; the 




Chondrodystrophia of slight degree, contrasted with ordinary rhaehitis, in sisters. 1. Chon- 
drodystrophia. Broad, short, very flexible hands; trunk disproportionately long; knock- 
knees. Age, five and a half years; height, 30% inches; normal height, 40 inches. 2. Rha- 
ehitis, bow-legs; age, four years; height 32 inches; normal height, 36 inches. 

head is large. The face is flattened and the skin may be thickening, 
the chest presents a pigeon-like distortion, and the epiphyses 
appear to be generally enlarged. In some instances the back 
is curved into a rigid kyphosis, or scoliosis and restricted motion 
or apparent fixation of many of the joints may be present, in others 
the joints are practically normal. 1 

1 Roos, Zeits. f. klin. Med., vol. xlviii. 



506 ORTHOPEDIC SURGERY 

Etiology and Pathology.— These cases were formerly sup- 
posed to be instances of intrauterine rhachitis. Chondrodystrophia 
is not, however, the result of a disturbance of nutrition; it is due 
apparently to a congenital defect in the bones themselves or rather 
of the original cartilage. Rhachitis is characterized by thickening 
about the epiphyseal cartilages and by delayed ossification. In 
chondrodystrophia, on the contrary, there is atrophy of the epi- 
physeal cartilages and abnormal rapidity of ossification. On 
section of a bone the shaft is seen to be thickened and stunted, 
the epiphyses are enlarged also, and these hypertrophied and 
prematurely ossified segments may overhang the diminutive car- 
tilage that intervenes and which may be partly or completely 
included in a periosteal expansion of connective tissue. 

Chondrodystrophia, or an affection resembling it, is sometimes 
seen (Fig. 314) in a very mild form; the appearance of the child 
suggests rhachitis, but the stunting of the growth is greater than 
is ever the result of rhachitis of corresponding severity. 

Cretinism. — Cretinism may cause a similar dwarfing of the 
stature, and may be combined with chondrodystrophia, but in 
most instances the symptoms of mental deficiency that accompany 
cretinism are lacking in this affection. 

Treatment. — The treatment of so-called foetal rhachitis con- 
sists in regular massage and manipulation of the distorted parts 
and of the anchylosed joints. This treatment must extend over 
several years, during which the limbs and back must be protected. 

Rest on the Bradford frame during the period of active treat- 
ment is advisable. If congenital cretinism is suspected the 
administration of thyroid extract would be indicated. 

Prognosis. — By persistent treatment the range of motion in 
the stiffened joints may be regained, but the prognosis as to 
growth is bad. The patients present in later years the abnor- 
mally long trunk and stunted extremities that were present at 
birth. 

Infantile Scorbutus. 

Synonyms. — Scurvy, scurvy rickets. 

Scurvy in infancy, as at other periods of life, is a constitutional 
disease dependent upon impaired nutrition, caused apparently 
by the deprivation of proper food. The disease was originally 
described by Smith and Barlow as scurvy rickets, but it may, 
and often does, occur independently of the latter affection. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 507 

Pathology. — The pathological changes most often found in 
cases of the advanced type are hemorrhages beneath the mucous 
membranes and the periosteum. Separation of the epiphyses 
may occur. 

Symptoms. — The disease is most often observed in bottle-fed 
infants from six to eighteen months of age. In some instances the 
patients are evidently ill-nourished, but in others they may appear 
to be in good condition. The early symptoms resemble rheu- 
matism. The child shows evidences of discomfort when certain 
joints, usually of the lower extremity, are moved, and as the 
disease progresses it may scream whenever it is turned or lifted. 
The painful joints are sensitive to pressure and they may be 
somewhat enlarged, but local heat and redness, as well as fever, 
are, as a rule, absent. After dentition the gums may be swollen 
and spongy, and hemorrhages into the skin or beneath the mucous 
membranes may occur. In extreme cases the swelling about a 
joint due to effusion of blood and accompanied, it may be, by 
separation of the epiphysis may be mistaken for the symptoms 
of infectious epiphysitis or even for sarcoma. 

Treatment. — The treatment consists primarily in the regula- 
tion of the diet, particularly in the substitution of fresh milk, 
properly modified, for the patent food or sterilized milk that 
may have been employed. This should be supplemented by 
orange-juice or that of other fresh fruit. The change of diet 
usually relieves the symptoms. During the painful stage of the 
disease complete rest in the horizontal position on a pillow or 
frame may be indicated; later, massage of the limbs and back 
may be of service in improving the nutrition and remedying 
slight deformity. 

Fragilitas Ossium. 

Synonym. — Idiopathic osteopsathyrosis. 

Idiopathic fragility or osteopsathyrosis is of congenital origin. 
The bones, particularly those of the lower extremity, are delicate 
in structure and usually short. The epiphyseal cartilages appear 
to be relatively normal but the periosteal growth of bone is defi- 
cient. In such cases there may be distortions at birth, apparently 
caused by intrauterine fractures, and in after-life fracture may 
follow the slightest accident or even sudden motion. Blanchard 1 
has reported a case in which there were seventy distinct fractures 

1 Transactions American Orthopedic Association, vol. vi. 



508 ORTHOPEDIC SURGERY 

between the ages of two months and twenty-seven years. A 
similar case was for many years under treatment in the Hospital 
for Ruptured and Crippled. For a part of the time the trunk 
and legs were enclosed in a plaster-of-Paris casing to prevent the 
fractures that followed even ordinary movements. At the age 
of fourteen the strength of the bones had increased sufficiently 
to enable the patient to walk about with the support of braces, 
but in stature he resembled a child of seven years. 

Fractures in this class of cases are attended with but little 
pain. They unite slowly with but a small callus. It is prac- 
tically impossible to prevent a certain amount of deformity. 
With advancing years the liability to fracture may diminish, 
but, as a rule, the patient is disabled and dwarfed in stature. 

The treatment is protective. Massage is of some service in 
improving local nutrition. Medication is of little avail. 1 

There are many other conditions that cause local or general 
fragility of the bones and thus an increased liability to fracture. 
Among the local causes are tumors, cysts, inflammatory processes, 
syphilis and the like. The general conditions would include the 
weakness of old age, sometimes called senile rickets; the atrophy 
caused by disuse incidental to chronic joint disease, or the weak- 
ness that may be caused by certain diseases of the nervous system. 
In other instances the weakening may be the direct result of 
disease, as, for example, osteomalacia or rhachitis. (See Atrophy 
of Bone, page 244.) 

Osteomalacia. 

Synonym.— Mollitis ossium. 

Osteomalacia is a disease of an inflammatory nature, charac- 
terized by an absorption of the earthy substances (decalcification) 
of the bones and by deformity. The disease is particularly one of 
adult life. It is far more common among females than males, and 
pregnancy, in about half of the cases that have been reported, 
seemed to be the exciting cause. The disease usually begins 
insidiously. The symptoms are pain on motion, referred to the 
pelvis and to the thighs. This is supposed to be of rheumatic 
origin until the character of the affection is made evident by the 
weakness of the limbs and by the deformities. These deformities 
are of greater interest to the obstetrician than to the surgeon, for 
when the affection complicates pregnancy the distortion of the 
pelvis may be so great as to prevent normal delivery. 

1 Porak, Bull, et M£m. de la Soc. Obst. et Gyn. de Paris, 1840. Salvetti, Beitr. zur 
path. Anat. und allg. Path., 1894, Bd. xvi. Nathan, Amer. Jour. Med. Sci., February, 1905. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 509 

Osteomalacia in Childhood.— Three cases of osteomalacia in 
childhood have been reported by Siegert, 1 and one case has come 
under my observation. The patient, one of twelve living children 
of healthy parents, was nursed by his mother for the usual period, 
and until the age of four years he appeared to be perfectly healthy. 
At this time, without known cause, general weakness became 
apparent, and at the same time deformities of the lower extremi- 



Osteomalacia in a child. 

ties developed. At the age of six years he was unable to stand. 
The condition of the patient at nine years of age is shown in Fig. 
315. There was no evidence of rhachitis or of paralysis. The 
patient had never suffered from pain or discomfort. The lower 
extremities were somewhat atrophied from disuse, the bones were 
abnormally flexible and were distorted to a moderate degree. 
The epiphyses were not enlarged. 

Treatment. — -As the etiology of the affection is unknown, the 
treatment is therefore experimental or symptomatic and palliative. 

1 Munch, med. Wochenschr., November 1, 1898. 



510 • ORTHOPEDIC SURGERY 

Local Osteomalacia. — When deformity of a bone appears and 
increases without apparent cause it is often assumed that a local 
disease — "local rickets or local osteomalacia" — is present. 

Local weakness and deformity may be caused by injury or by 
subacute osteomyelitis and the like. If there is a distinct local 
disease that deserves the name of local osteomalacia its cause 
has not been determined. 



Osteitis Deformans. 

This disease was first described by Paget 1 in 1877. It is a 
chronic inflammatory affection of the bones, characterized by 
hypertrophy and softening. " The bones enlarge, soften, and those 
bearing weight become unnaturally curved and misshapen." 




Osteitis deformans in a female seventy-three years of age. (Lunn. 2 ) 

Section of an affected bone shows it to be markedly increased 
in size, and somewhat in length, by a combination of rarefying 
and formative osteitis. The inner layers become porous, and at 
the same time new bone is deposited beneath the periosteum. 

The disease appears to be confined to adult life, and it is 
apparently more common among males than females. Of 67 
cases collected by Packard, Steele, and Kirkbride, 3 61 per cent, 
were in males. 

As a rule, the lesions are symmetrical and general in dis- 
tribution, the bones of the lower extremity, the skull, and the 
spine being more often involved. Thus the head progressively 
increases in size, and the legs become bowed. If the spine is 

1 Med. Chir. Trans., vols. xl. and lxv. 

- Prince, American Journal of the Medical Sciences, November, 1902. 

3 American Journal of the Medical Sciences, November, 1901. 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 511 

affected it bends forward, forming a long, more or less rigid 
kyphosis. 

Aside from the deformities and the characteristic enlargement 
of the bones, the symptoms are not marked. At times complaint 
is made of pain usually supposed to be rheumatic until the char- 
acteristic changes in the bones appear. The disease is extremely 
chronic in its course, and, as a rule, the general health is not 
seriously affected. In several instances sarcoma of bone finally 
caused death many years after the onset of the disease. Its 
etiology is unknown, and its treatment is palliative. 




Normal tibia and foot. 



Osteitis deformans. Hyperostosis and 
decalcification. (Fitz.) Contrast with Fig. 
317. 



Local Osteitis Deformans.— A disease resembling in its general 
characteristics osteitis deformans may appear in a single bone 
or in corresponding bones of the lower extremity (Fig. 319). It 
may persist indefinitely, with but little tendency toward the general 
involvement of the bones characteristic of Paget's disease, whether 
it is a variety of osteitis deformans or is of another class is not 
apparent at present. The treatment is symptomatic, being directed 
especially toward relief of strain that induces discomfort and in- 
creases the deformity. 



512 



ORTHOPEDIC SURGERY 



Secondary Hypertrophic Osteoarthropathy. 1 

Osteoarthropathy is an inflammatory disease of the bone char- 
acterized by hypertrophy, clubbing of the fingers, and effusion 
into certain of the joints. The hypertrophy is caused by a deposi- 
tion of layers of bone beneath the 
periosteum of the metacarpal and 
metatarsal bones, the phalanges and 
the distal extremities of the adjoining 
bones of the arms and legs. Less 
often the area of the disease is more 
extensive, involving the femora, the 
humeri, and the spine even. 

Osteoarthropathy is usually a com- 
plication of pre-existing chronic dis- 
ease, most often of the lungs. The 
patient first notices clubbing of the 
terminal phalanges and hypertrophy 
of the finger-nails, later an increasing 
enlargement of the wrists and ankles, 
and of the hands and feet, accom- 
panied by discomfort, sensitiveness 
to pressure, and often by effusion into 
the neighboring joints, symptoms that 
would be classed as rheumatic were 
it not for the evident hypertrophy. 

The clubbing of the fingers is due, 
in part at least, to impairment of the 
circulation, and the connection of the 
disease of the bones with that of the 
lungs has suggested the theory that 
it is caused by the absorption of 
toxins, and that its etiology is similar 
to the amyloid hypertrophy of the 
internal organs that sometimes fol- 
lows chronic disease of bones and 
joints attended by suppuration. The treatment is symptomatic, 
and as the affection is almost always secondary to graver disease, 
but little is known of its outcome. It is certain, however, that the 
secondary osteoarthropathy symptoms become less marked or may 




Osteitis deformans of both femora 
most marked on the right side. Dura- 
tion of symptoms 3 years. Symp- 
toms increasing outward bowing of the 
limbs, also pain and weakness after 
overexertion. 



1 Marie, Revue MSdicale, Paris, 1890, 
No. 11; Deutsche Chir., 1S99, L. 28. 



1. Bamburger, Wiener klin. Woch., 1889, 



AFFECTIONS LEADING TO GENERAL DISTORTIONS 513 

even disappear as the patient recovers from the original disease of 
the lungs or other organs. The affection is very uncommon in 
childhood. In one characteristic case observed by the writer com- 
plete recovery followed the cure of Pott's disease and chronic 
bronchitis, the hypertrophied phalanges alone remaining. 1 



Acromegalia. 

This affection is also characterized by progressive enlargement 
of the hands and feet, but it differs from osteoarthropathy in that 
all the tissues are involved in the hypertrophy. The hypertrophy 
of the bone is limited to the extremities, and is slight compared 
with that of the soft parts. The face is often involved, the tissues 
of the nose, lips, and ears being enlarged and thickened, together 
with the underlying bones, so that the expression is very markedly 
changed. 

Acromegalia is common among those of gigantic stature, the 
local hypertrophy and the gigantism both being due, it is sup- 
posed, to disease of the pituitary gland. 

Diagnosis. — The three affections that have been described — 
osteitis deformans, osteoarthropathy, and acromegalia — are rare 
diseases, and they are of little practical interest to the surgeon 
other than from the standpoint of diagnosis. This might be 
somewhat difficult if the pathological process were confined to a 
single bone or limb, as is sometimes the case in osteitis deformans. 

The essential characteristics of the three diseases may be sum- 
marized as follows: In osteitis deformans the entire bone is 
increased in size and length, and because of the coincident weak- 
ening of its structure it becomes distorted; the skull is usually 
involved, but the hands and feet are not often affected. It is a 
disease of middle or later life, and there are, as a rule, no symp- 
toms other than those due to the local changes in the bones. 

In osteoarthropathy the process is an hypertrophy of a slight 
degree, caused by deposition of periosteal bone, especially about 
the distal extremities of the shafts of the bones adjoining the 
hands and feet. It is not often accompanied by the weakness or 
the deformity that is characteristic of the preceding affection; 
the skull is not usually involved, but the long bones of the hand 
and feet are thickened, so that these members are markedly 
increased in size. There is often coincident discomfort and swell- 

1 Whitman, Pediatrics, February 15, 1899, 

33 



514 ORTHOPEDIC SURGERY 

ing of the neighboring joints. As a rule, the local affection of 
the bones is secondary to chronic disease of the lungs. 

In acromegalia the marked changes are hypertrophic enlarge- 
ments of the hands and feet in which all the tissues are involved; 
the hypertrophy of the bones is most marked about the epiphyses, 
the diaphyses remaining unaffected; thus it differs from the 
preceding disease, in which similar enlargement of the extremities 
occurs. The head is often involved, but the hypertrophy is of 
all the structures of the face, not of the skull, as in osteitis 
deformans. 

The disease appears to be confined to early adult life, and 
it is often preceded or accompanied by symptoms of a general 
nature, headache, mental impairment and the like. 

The changes in the bones characterizing the affections may be 
easily demonstrated by means of the Roentgen pictures. 



CHAPTER XV. 

CONGENITAL DISLOCATION OF THE HIP AND COXA VARA. 

Congenital Dislocation at the Hip-joint. 

Of all the congenital dislocations, or, perhaps, more properly, 
misplacements, that of the hip-joint is by far the most common 
and the most important. 

Statistics. — Congenital dislocation of the hip is much more 
common in females than in males. In 1362 cases collected from 




Congenital dislocation of the hip, showing the elongated capsule and the right-angled 
relation of the neck to the shaft of the femur. (William Adams.) 

different sources by Hoffa, 1189 (87.2 per cent.) were in females 
and 173 (12.7 per cent.) in males. Of 1039 cases seen at the 
Polyclinic in Milan, 867 (83.4 per cent.) were in females, 172 



51 6 ORTHOPEDIC SUEGEB Y 

(16.6 per cent.) in males. 1 In 801 cases from the records of the 
Hospital for Ruptured and Crippled, 655 (81.6 per cent.) were 
in females and 146 (18.3 per cent.) in males. 

The dislocation is more often unilateral than bilateral. In 
Hoffa's series of 1362 cases 860 (63.1 per cent.) were single; 392 of 
the right, 468 of the left side. In 502 cases (36.9 per cent.) the 
displacement was bilateral. 

Statistics of 801 Cases of Congenital Dislocation of Hip, Recorded 
at the Hospital for Ruptured and Crippled. 

Per cent. 

Males 146 18.35 

Females 655 81.65 

801 100.00 

Right hip 206 26.07 

Left hip 353 44.69 

Both 231 29.24 

790 100.00 

Not specified 11 

801 

Males. 

Right hip. . 43 30.49 

Left hip 55 39.02 

Both 43 30.49 

141 100.00 

Not specified 5 

146 

Females. 

Right hip 163 25.10 

Left hip 298 45.94 

Both 188 28.96 

649 100.00 

Not specified 6 

655 

The dislocation at the time when the patients are brought for 
treatment is usually posterior, upon the dorsum of the ilium; in 
other instances it is anterior, and the head of the bone may be 
felt beneath the anterior superior spine. It is probable, however, 
that the primary displacement is often directly upward, for in 
those cases discovered in infancy this position is common. 

Pathology. — The pathological anatomy of the dislocation was 
first clearly demonstrated by Dupuytren in 1826, and since 1890, 
when the open operation was first performed, the exact relation 
and the appearances of the different components of the joint have 
been described in detail by Hoffa, Lorenz, and other operators. 

1 Bernacchi, Zeits. Orth. Chir., vol. ii. p. 275. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 517 



The condition of the joint varies with the age of the patient 
and the strain and friction to which the displaced parts have 
been subjected. In early infancy it may be assumed that the 
head of the bone lies in close proximity to what is, in some in- 
stances, a practically normal acetabulum; in others to one that 
is somewhat rudimentary, often shallow and small, sometimes of 
an oval or of a somewhat triangular shape. The acetabulum is 
covered with normal hyaline cartilage, the ligamentum teres is 
present, and the capsule is of nearly normal structure. At a later 
time, when the joint is exposed at operation at the age of five or 
more years, the capacity of the rudimentary acetabulum may be 
lessened by a deposit of fat 

and fibrous tissue. As a rule, FlG - 321 

however, it appears to be of 
fair size and depth. The 
capsule is elongated to accom- 
modate the upward displace- 
ment of the femur. It is hy- 
pertrophied, especially where 
it covers the upper part of the 
head of the bone, and it may 
be drawn into a shape like an 
hour-glass; the upper part 
contains the head of the bone ; 
the anterior wall is drawn 
tightly across the acetabulum , 
forming at its upper border a 
narrow slit-like communica- 
tion, through which the liga- 
mentum teres passes if it be 
present (Fig. 321). The in- 
terior of the capsule is in part 
lined with synovial membrane, and it often contains more synovial 
fluid than is found in the normal joint. 

The ligamentum teres, although probably present at birth in 
a large proportion of the cases, becomes attenuated and ribbon- 
like with the increasing elongation of the capsule, and after the 
age of five years, or at the time when the open operation is per- 
formed, it is usually absent, and far more often in the bilateral 
than in unilateral cases. According to Lorenz, in 52 cases between 
two and a half and five years it was present in 17; in 48 cases 
beyond the age of five years it was present in but 4. In rare 




Congenital dislocation of the hip, showing the 
original and the acquired acetabula. (Lorenz.) 



518 



ORTHOPEDIC SURGERY 



instances it may be hypertrophied. In my own experience the 
ligament is present in a very much larger proportion of the cases, 
although it is often so rudimentary that it might easily be over- 
looked. 

A shallow secondary acetabulum, formed in part by the direct 
pressure of the head of the bone through the adherent capsule, 
and in part the result of irritation of the periosteum, is usually 
found upon the ilium (Fig. 322), but it is not often of sufficient 





Congenital dislocation of the hip in adult age, showing the abnormal shape of the ace- 
tabulum, the depressions in the ilium caused by the pressure and friction of the head of the 
femur, and the destructive effect of this pressure and friction upon the femur. (Adams.) 

depth to assure a secure support for the head of the femur; thus 
its upper margin gradually recedes or two distinct depressions 
may be formed, one above the other. The upper extremity of 
the femur is usually somewhat atrophied. The neck is often 
shorter than normal, and its angle may be lessened, and in many 
instances its forward inclination is increased. The head of the 
bone may be nearly normal, although usually it is somewhat 
flattened on its posterior and under surface, or it may be somewhat 
conical, acorn-like in shape, or again compressed from side to 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 519 

side to an almond shape or otherwise distorted. The abnormal- 
ities, in part congenital, become more marked with age, and in 
adult specimens the head and neck of the femur may be so atro- 
phied and worn away as to present but little semblance of normal 
contour (Fig. 322). 

There are secondary changes in the bones of the pelvis. In 
unilateral dislocation the pelvis is usually somewhat atrophied 





Unilateral dislocation, showing the incli- 
nation of the body toward the shorter 
leg. 



The same patient before operation, show- 
ing the abnormal lordosis and rotation 
of the pelvis. (See Figs. 351 and 352.) 



on the affected side, and a lateral inclination of the spine may be 
present. The final changes in the pelvis caused by the bilateral 
dislocation are more important; its inclination is increased, the 
lumbar lordosis is exaggerated, the sacrum is forced forward and 
downward so that the anteroposterior diameter is diminished ; the 
tuberosities of the ischia are everted and the transverse diameter 
of both the inlet and outlet of the pelvis is increased. 



520 ORTHOPEDIC SURGERY 

The long muscles of the thigh are shortened, while those attached 
about the trochanter are changed in direction and are usually 
lengthened. There is also a slight general muscular atrophy 
that is particularly marked in the gluteal group. 

The changes that have been described are in great degree 
secondary to the displacement. They are in part congenital, in 
part accommodative, and in part due to the influences of attrition 
and injury, to which the abnormal mobility predisposes. Thus, 
as a rule, they become more marked with increasing age, and in 
some of the adult specimens but little resemblance to the normal 
parts remains. 

As a rule, congenital dislocation of the hip is not accompanied 
by defective development or deformity elsewhere, although cases 
are sometimes seen in which a general laxity of ligaments is present 
or in which the dislocation may be one of a series of deformities 
and malformations. 

Etiology. — Nothing positive is known of the etiology of the 
dislocation. In a small proportion of the unilateral cases it may 
be due to violence at birth, but the fact that nearly 85 per cent, 
of the patients are females makes it evident that the primary 
cause can be neither injury nor disease. 

Hereditary influence can be established in a few instances. 
The writer has examined three female children in a family of 
nine, in each of whom there was dislocation of the left hip, the 
order being the third, eighth, and ninth child. Also twins in 
another family, one having single and the other double dislocation. 
And in four instances congenital displacement was present in the 
mothers of patients. Vogel, 1 from an investigation of 200 cases 
concludes that heredity might have had some remote influence 
in 30 per cent. — viz. : In 6 instances the mother had congenital 
dislocation, in 9, the father, in 7 sisters of the father, in 8 sisters 
of the mother, in one, both father and mother. In 25 per cent, 
of the cases there had been breech presentation. 

Of the various theories that have been advanced to account for 
the condition, the most reasonable seems to be a predisposing 
attitude of flexion and adduction abnormally prolonged in utero. 
Dislocation at this joint is relatively frequent because the 
acetabulum is shallow in fcetal life. According to Sainton's 
observations, in newborn children it covers but one-third of the 
femur, but at the age of five years it is sufficiently deep to contain 
one-half of it. 

1 Deutsch. Zeits. f. Chir., 71., Bd. iii. and iv. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 521 



Heusner and Marcwald 1 , from an examination of eighty-five 
foetuses, conclude that the greater liability of females to the dislo- 
cation is explained by the disproportionate laxity of the capsule 
as compared with males. 

It is probable that the dis- FlG - 325 

location, in some cases at 
least, is at birth a sublux- 
ation only, that becomes 
complete through muscular 
action and by the use of 
the limb in standing and 
walking. 

Symptoms. — The dis- 
placement does not, as a 
rule, attract attention until 
the child begins to walk, 
although in some cases the 
mother may have noticed a 
peculiar breadth of pelvis, 
or a "lump" on the buttock, 
or a "snapping" about the 
hip-joint, or a peculiar atti- 
tude of the limb before this 
time. 

Unilateral Dislocation. — If 
the displacement is of one 
side, a limp is immediately 
apparent, which becomes 
more noticeable as the child 
grows older. The limp is 
peculiar, and its character 
is explained by its cause ; for 
the shortened limb, owing to 
the elasticity of the capsule, becomes still shorter when the weight 
falls upon it; thus in walking there is a peculiar lunge of the body 
toward the short side, that has been likened to the motion in walk- 
ing down stairs. In the ordinary form the head of the femur 
is displaced upward and backward, and in compensation the 
pelvis is tilted toward the short limb and its inclination is increased; 
it is thus twisted downward and forward so that the anterior 




Congenital dislocation of both hips, illustrating 
the separation of the thighs, the abnormal breadth 
of the pelvic region, and the prominent trochanters. 



Zeits. f. Orth. Chir., 1902, Bd. x., H. 4. 



522 



ORTHOPEDIC SURGERY 



superior spine lies at a lower level and in advance of that of the 
opposite side (Figs. 323 and 324). 

At an early age the shortening of the limb, due to the elevation 
of the trochanter, is from one-half to three-quarters of an inch. 
In later childhood the elevation is from one and one-half to two 
inches, and in adult life it may be considerably more. 




Bilateral congenital dislocation of the hip, showing the exaggerated lordosis. 

The effect of the displacement is also shown by a flattening of 
the buttock, and usually the elevated and prominent trochanter 
may be seen as an abnormal lateral projection, on a level with 
the anterior superior spine, which is, as has been stated, some- 
what tilted downward. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 523 

In infancy motion in the false joint is more free than normal, 
and the abnormal mobility can be demonstrated by alternate 
traction and upward pressure on the limb, but as the femur be- 
comes larger and the upward displacement increases the mobility 
is restricted. The range of abduction is much diminished, and 
in extreme cases the limb may become permanently adducted 
and flexed, thus adding the apparent shortening of adduction to 
that caused by the dislocation (Fig. 327). 

Bilateral Dislocation. — When the dislocation is bilateral the 
shortening of the limbs is, as a rule, equal or nearly so, and if, as 
is usual, both femora are displaced backward, the pelvis is tilted 
forward; thus in compensation "the hollow" of the back is 
increased, the abdomen protrudes, the buttocks are flattened, the 



Congenital dislocation in an adolescent, illustrating the flexion contraction 
in a well-marked case. 

pelvis appears to be abnormally wide, and the thighs are sepa- 
rated by a considerable interval (Figs. 325 and 326). The limp 
characteristic of the single displacement is replaced by an exag- 
gerated waddle, a "sailor gait." 

General Symptoms. — In early childhood there are no special 
symptoms other than the limp or the waddle, but as the child 
becomes more active it usually complains of discomfort after 
exertion. It is easily fatigued, and at times it. may suffer actual 
pain. These symptoms are, of course, more marked in the double 
than in the single displacement, because in the latter case the 
normal limb is capable of bearing more than its share of the strain. 
The symptoms often increase during adolescence, but they may 
become less troublesome in adult life, when the head of the bone 
may have found a permanent resting place on the pelvis; a security 



524 



ORTHOPEDIC SURGERY 



Fig. 328 



which is often assured by a corresponding limitation of the range 
of motion. The shortening and the secondary effects of the dis- 
placement, of course, persist, so that the individual is, as com- 
pared with the normal standard, more or less disabled and in 
certain instances noticeably deformed. 

The great majority of the patients are females, and, because 
of the less laborious occupations and the dis- 
tinctive dress, the disability and its effects are 
less serious than if the displacement were 
more equally divided between the sexes. 

Anterior Dislocation. — The symptoms of the 
unilateral anterior dislocation, in which the 
head of the bone lies beneath the anterior 
superior spine, are much less marked than in 
the ordinary form because the relation of the 
pelvis to the femur is nearly normal ; so that 
secondary deformity is slight. The shortening 
is less and the limp is less noticeable because 
the resistance of the tissues attached to the 
anterior superior spine is sufficient to assure 
a relatively secure support. 

In bilateral anterior dislocation the entire 
body is swayed slightly backward, but the 
lumbar lordosis is not increased; in fact, the 
back is often peculiarly flat. Otherwise the 
symptoms do not differ, except in degree, from 
those of the posterior displacement (Fig. 328). 
Supracotyloid Displacement. — As has been 
stated, in early cases the displacement may be 
a form of subluxation in which the head lies 
but slightly above the normal position. The 
same upward displacement is occasionally 
found in older subjects. The physical signs are 
similar to those of the anterior displacement. 
Diagnosis. — The diagnosis offers no diffi- 
culty. The history of the limp or waddle 
noticed when the child began to walk and yet unaccompanied 
by pain or preceded by injury or disease is in itself sufficiently 
distinctive. If the displacement is of one side, measurement 
demonstrates the shortening as compared with the other limb, 
a shortening that is explained by the prominence and the eleva- 
tion of the trochanter above Nelaton's line. Traction and 



Bilateral anterior con- 
genital dislocation. The 
lordosis is far less marked 
than in the ordinary form. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 525 

upward pressure on the leg will demonstrate the abnormal 
mobility of the displaced head; and finally, if the thigh be flexed 
and adducted to its extreme limit, the neck and head of the femur 
can be easily distinguished moving under the gluteal muscles 
when the limb is rotated. Thus it may be differentiated from 
depression of the neck of the femur (coxa vara), in which, although 
the trochanter is elevated, the neck and head of the bone cannot 
be felt, and in which the abnormal mobility, characteristic of the 




Bilateral' congenital dislocation of the hip. 

dislocation, is absent. Again, coxa vara is almost never a con- 
genital affection; therefore, the history itself would practically 
exclude it. 

Upward displacement of the femur not infrequently follows 
infectious epiphysitis or arthritis of infancy or early childhood. 
In such cases a part of the upper extremity of the bone is usually 
destroyed, so that the head cannot be distinguished on palpation. 
Although the other physical signs are similar to those of the 
congenital displacement, the scars about the joint present the evi- 



526 



ORTHOPEDIC SURGERY 



dence of former disease, and the history is almost always available 
for diagnosis. Thus, as a rule, such disabilities, as well as trau- 
matic dislocations or other results of injury or disease, are readily 
excluded. 

The bilateral dislocation presents, of course, the same physical 
signs as the single form; it is even more easily recognized by the 
peculiar appearance and distinctive gait of the patient. The 
waddling gait may be simulated by 
that of extreme bow-legs, but the hip- 
joints are, in this deformity, normal 
in appearance and function. The 
swagger of lumbar Pott's disease is 
also somewhat similar, but this is an 
acquired painful disease of the spine, 
in which the hip-joints are normal in 
appearance and usually so in function 
Pseudohypertrophic paralysis may 
be mentioned as causing a somewhat 
similar gait and attitude, but here the 
resemblance ceases. 

As has been stated, the diagnosis 
of congenital dislocation can be 
easily made by physical examina- 
tion; the only real difficulty is ex- 
perienced in certain dislocations or 
subluxations of the anterior type and 
in cases seen in early infancy in which 
the dislocation may be incomplete, 
but opportunity for such early diag- 
nosis is rarely offered. In doubtful 
cases a Roentgen picture will de- 
monstrate the character of the dis- 
ability (Fig. 329). 

Treatment. — Dupuytren, in 1829, 
after a careful study of the anatomy 
of the deformity, came to the con- 
clusion that it was not only incurable but that palliation of its 
effects even was hardly attainable ; and for sixty years the state- 
ment was generally accepted, although cures were attained in all 
probability by Pravaz, of Lyons, 1847, and at a much later time 
by Paci, of Pisa, 1887. 

The term dislocation naturally suggests replacement and reten- 




Bilateral dislocation in adolescence. 
This patient was practically disabled 
by pain and weakness. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 527 

tion of the displaced bone in its proper place, and in 1890 Hoffa 
first performed this operation with success by opening the joint 
from behind and enlarging the rudimentary acetabulum to a size 
sufficient to contain the head of the bone. The details of the 
operation were afterward modified by Lorenz, 1 and at the present 
time the original operation has been to a great extent supplanted 
by bloodless reposition, but to Hoffa belongs the credit for the 
introduction of the modern treatment of this disability. 

The Lorenz Operation of Bloodless Reduction, Retention, 
and Weight Bearing. 

This treatment is based on the experience obtained by the 
open treatment that an acetabulum of fair size is practically 
always present. This acetabulum is not of sufficient capacity to 
retain the head of the femur when the limb is in the normal attitude, 
but it is sufficiently deep to permit of retention when the limb 
is fixed in abduction. 

It has been proved, also, that by traction and leverage the 
head of the femur in most instances may be forced into direct con- 
tact with the rudimentary acetabulum. Once this contact or 
reposition is attained, the limb must be fixed to prevent dis- 
placement, and as soon as possible the patient must stand and 
walk in order that weight and friction may deepen the rudimen- 
tary acetabulum. Meanwhile the distended capsule and other 
tissues contract about the new joint, and the muscles become 
accustomed to their new functions. That the acetabulum may 
be actually enlarged by the presence of the head of the femur is 
proved by the fact that secondary depressions of sufficient size to 
form joints of fair stability are often found upon the pelvis in 
anatomical specimens from older subjects. 

The Lorenz Operation. — The first step in the operation is to over- 
come the resistance of the tissues, namely, of the capsule and of 
the long muscles that have become structurally shortened in 
accommodation to the upward displacement of the head of the 
femur. The second step is to reduce the dislocation, or rather 
to force the head of the femur over the posterior or upper border 
of the acetabulum. The third is to increase the security of the 
articulation by stretching the anterior border of the capsule. The 
fourth is to fix the parts securely in a plaster bandage. 

1 Pathologie und Therapie der Angebornen Hoeft. Verrenkung, Wien, 1895; Ueber heilung 
der Angebornen Hoeftgelenk Verrenkung, Leipzig u. Wien, 1900. 



528 ORTHOPEDIC SURGERY 

The patient is placed upon a table with a thick folded sheet 
beneath the buttocks. The assistant, standing opposite the oper- 
ator, fixes the pelvis with his hands (Fig. 331). In some in- 
stances better control is assured by pressing the flexed thigh of 
the sound side downward against the abdomen, as in the Thomas 
test for flexion in hip disease. 

The operator first flexes the thigh to a right angle with the 
body, then forcibly abducts it, at the same time kneading the 
tense muscles with the ulnar border of the hand, stretching and 
rupturing the fibres until the normal prominence has entirely 
disappeared. The stretching is continued until the limb can be 




Reduction of dislocation of the right hip. First step. The operator overcomes the 
resistance offered^by the adductors by forcible massage. 

forced down to the plane of the body. One next overcomes the 
shortening of the tissues on the posterior aspect by flexing the 
limb, extended at the knee, upon the trunk, gradually forcing it 
downward until the toes may be placed against the patient's face 
(Fig. 332). During this manoeuvre the assistant fixes the pelvis 
by holding the extended thigh of the sound side firmly against the 
table. The next step is to overcome the resistance of the tissues 
on the front of the joint. The pelvis is fixed by the assistant. 
The leg is then flexed upon the thigh, and the thigh is forced 
downward behind the plane of the body, or the patient may be 
turned upon the side, as in Fig. 333. After this preliminary 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 529 




Forcible flexion of the extended limb on the abdomen. Second step in the operation. 
Fig. 333 




Forcible extension of the thigh. Third step in the operation. 
34 



530 OB TBOPEDIC SURGERY 

stretching, traction is made upon the limb, and if with slight 
effort the trochanter can be drawn down to Nekton's line reduc- 
tion is attempted. 

Reduction. — The pelvis having been fixed as in the first position, 
the limb is slowly and forcibly abducted over a wedge of wood 
suitably padded, the apex of which is placed between the tro- 
chanter and the pelvis (Fig. 334). As the limb is gradually 
forced downward to and behind the plane of the body, the head 
of the femur is forced upward until it finally snaps over the pos- 
terior border of the acetabulum. Reduction is usually accom- 
panied by a distinct jar, and often by an audible thud. It is also 
indicated by tension upon the posterior muscles of the thigh, which 
causes fixed flexion of the leg. An effort is now made to increase 
the capacity of the joint. The patient is turned upon the sound 




Reposition. The thigh is forcibly abducted over the padded wedge. Fourth step in 
the operation. The wedge is of hard wood of the following dimensions: length, 9J^ inches; 
height, 3K inches; base, 3 inches. 

side and the pelvis, having been fixed by the assistant, the operator 
draws the thigh over and over again behind the plane of the body, 
and at the same time rotates it from side to side. The security 
of the reposition is then determined. One tests successively 
the stability or depth of the superior margin of the acetabulum 
by reducing the abduction ; of the posterior margin by lifting the 
thigh ventralward, and in a similar manner the inferior border. 
Upon this examination the prognosis is made; if the stability 
allows an approximation to the normal position before displace- 
ment occurs the prognosis is good. If, on the other hand, the 
margins of the acetabulum are so ill-formed that displacement 
occurs very easily the prognosis is bad. 

The operation is varied somewhat in certain instances. If 
after the stretching the trochanter still remains above Nela ten's 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 531 

line, one attempts to overcome the remaining resistance by direct 
traction in the line of the body. Counter-resistance is furnished 
by a folded sheet passed between the thighs about the perineum, 
the two ends of which are tied about a corner of the table. Trac- 
tion on the limb is made by one or two assistants while the operator 
supports the pelvis and presses downward and inward upon 
the trochanter. Occasionally reposition is effected during this 
manoeuvre — that is, the head is drawn over the superior instead 
of the posterior border of the acetabulum. 

Preliminary Traction. — In the treatment of older patients or 
of more resistant cases preliminary traction in bed is advisable. 







Reposition in young subjects, the thumb being used as the fulcrum to reduce the left hip. 

The traction must be considerable, and heavy weights, if possible 
up to forty pounds or more, should be employed for two or more 
weeks. This is of great advantage. 

Reduction in Two Sittings. — If the reduction is more than usually 
difficult, requiring more force than is deemed safe, the limb 
should be fixed in a plaster spica in the attitude of abduction, 
the actual reposition being deferred for one or more weeks. At 
the second operation the reduction can be easily accomplished 
in 11 most instances. 

Reduction in Young Subjects. — In younger subjects the wedge 
is not necessary, the thumb of the operator being used as a 



532 ORTHOPEDIC SURGERY 

fulcrum beneath the trochanter to lift and push the head upward 
while the limb is abducted. In this class of cases much less 
force is required in the preliminary stretching (Fig. 335) and in 
the treatment of very young subjects reduction may often be 
effected by simply abducting the limb. 

After reposition has been accomplished and when the greatest 
possible stability is assured by abducting the thigh again and 
again and forcibly rotating it from side to side to stretch the con- 
tracted anterior wall of the capsule and by extending the leg upon 
the thigh, to thoroughly overcome the resistance of the hamstring 
muscles the plaster bandage is applied. A close-fitting stock- 
inette shirt, of which one-half has been cut and sewed to cover 
the limb as a drawer, is drawn on over the limb, threaded as it 







'■^^^M 






~%*m 




\ 



The position in which the limb i.s held when the plaster band ige is applied. 

were, with a long bandage, the "scratcher." The patient is 
then placed upon the pelvic rest and the limb is held in the posi- 
tion of greatest stability at a right angle with the trunk and 
lying behind the plane of the body. The pelvis and thigh are 
thoroughly and thickly covered with layers of sheet-wadding or 
cotton. This is bandaged firmly, to assure a slight elastic com- 
pression (Fig. 336). 

The plaster spica is then applied. This should be thick and 
firm, at least a dozen and oftentimes many more of the ordinary 
size being used by Lorenz. These bandages are drawn snugly 
around the pelvis and thigh by a series of reverses and figure-of- 
eight turns, clasping the iliac crests and thoroughly covering 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 533 

in the buttock. The support is cut away, to allow motion at the 
knee-joint, especial care being taken to evert the edges and thus to 
prevent pressure. The ends of the shirting are then drawn 
smoothly over the bandage and are sewed to one another (Figs. 
337 and 338). 

The operation is usually followed by swelling and discoloration 
in the adductor region and more or less pain, of a starting, 
spasmodic character, especially when the leg is moved. This soon 
passes away, usually during the first or second week, and the child 
is then encouraged to stand. As it is only with extreme difficulty 
that the foot on the operated side can be brought to the floor, a 
cork-soled shoe from one and a half to three inches in height is 
usually worn to facilitate walking. 




A plaster bandage applied by Lorenz, illustrating the extreme thickness of the pelvic 
portion and discoloration of the adductor region. 

As has been stated, walking is encouraged on the theory that 
weight bearing and the stimulation of functional activity will 
increase the stability of the joint by deepening the acetabulum 
and accentuating its boundaries. In most instances the range 
of extension at the knee is for a time somewhat restricted. This 
restriction is overcome by passive force and by the voluntary 
effort of the patient. The first bandage is allowed to remain in 
place for from three to six months, the skin being kept in good 
condition by daily vigorous rubbing with the band beneath the 
supporting bandage. In addition the leg should be regularly 
massaged ; after a few weeks the bandage becomes loose about the 
pelvis. This will permit rubbing of the buttocks. One is able 



534 



ORTHOPEDIC SURGERY 



also by palpation of the anterior region to ascertain whether or 
not the head of the femur is in proper position. In young children 
the bandage must be changed as often as it becomes offensive. 
In from three to six months it may be supposed that the 
accommodative contraction of the muscles about the joint and 
of the capsule will lessen the danger of redisplacement. The 




Unilateral congenital dislocation, showing the fixation bandage. A shoe with a cork 
sole about two inches in height should be worn on the operated side, while the attitude of 
exaggerated abduction is maintained. 

limb is then let down somewhat so that the patient is able to walk 
about without the aid of a high shoe. The second bandage is 
retained for three months or more, and it is then removed, the 
period of retention being from six to twelve months, according 
to the stability of the joint at the time of reduction. In the treat- 
ment of very young children, when in testing the stability at the 
time of operation the femur is not displaced, even when the normal 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 535 

position is approached, the limb may be fixed by the plaster in 
a less distorted attitude— what Lorenz calls the indifferent position 
of flexion, abduction, and outward rotation. 

So, also, when the tests at the operation show fair stability a 
second bandage need not be applied after a preliminary reten- 
tion of from six to nine months, or even a much shorter time if 
proper supervision can be provided, but it is better to err on the 
side of safety in the matter of fixation. 

When the retention bandage is finally removed the attitude of 
moderate abduction and outward rotation persists for a time, in 
some instances for several months. This being an indication of 
stability, is considered a favorable sign, and no attempt is made 
to correct it. If, on the other hand, as in the older class of 




Illustrating the limitation of the range of abduction in the attitude of right angular 
flexion in bilateral dislocation. Compare with Fig. 341. 

patients, the fixed abduction persists the patient should be anaes- 
thetize:! and the contracted tissues carefully stretched. In most 
cases of this character the cause of the distortion is a partial 
pubic displacement, the head of the bone forming a well-marked 
projection beneath the femoral artery. This projection may be 
reduced by flexing the limb, and in certain instances it may be 
well to fix the limb for a time in a slightly flexed position until 
the tendency toward the anterior displacement is lessened. In 
the after-treatment the limb is massaged, particularly the posterior 
and lateral muscles of the hip, and the child is encouraged to 
abduct and to extend the thigh, and bearing the weight on the 
operated limb to sway the other limb laterally to the extreme 



536 ORTHOPEDIC SURGERY 

limit. Passive movements are made, also, in the direction of 
abduction and extension, the ability to reproduce the first or 
operation position during the early treatment being considered 
essential. In certain instances the child for a time should sleep 
in this position, the attitude being assured by placing the child 
in a support of plaster corresponding to the posterior half of the 
original spica. 

Bilateral congenital dislocation is treated in exactly the same 
way as the unilateral. Both hips are operated upon at one sitting, 
and are fixed in the typical attitude (Fig. 334). Walking is, of 
course, difficult, but the child is usually able to stand, and after 
several months it is often able to get about on its feet after a 
fashion (Fig. 342). 




The after-treatment following t he removal of the bandage in a case of bilateral dislo- 
cation, illustrating hyperextension of the thighs. 

When the second bandage is applied the limbs are let down 
somewhat, but the degree depends, of course, on the initial stability. 
The after-treatment is the same as for the single dislocation, 
except, of course, that the subsequent period of awkwardness is 
much longer. Massage and exercises (Fig. 340) are far more 
important than in single dislocation, as the weakness is greater. 
The primary position during sleep may be assured by a cushion 
or roll placed between the thighs. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 537 

Prognosis. — The Lorenz operation is not without danger. The 
death-rate attributed to anaesthesia is disproportionately large in 




Illustrating the range of normal abduction of the thighs, from the attitude of right 
angular flexion. 




The bandage applied after the reduction of bilateral dislocation, showing a favorite 
method of progression on a chair. 



the cases reported, and in this the violence of the manipulations 
is undoubtedly an important factor. 



538 ORTHOPEDIC SURGERY 

In 450 operations reported by Lorenz the following accidents 
occurred : 

Fracture of the neck of the femur in .11 cases 

Fracture of the pelvis in 3 " 

Peroneal paralysis in 3 " 

Crural paralysis in 5 " 

Sciatic paralysis in 3 " 

In the last cases the paralysis persisted; in the others it was 
temporary. In one case the femoral artery was ruptured, the 
patient recovering without ill-effect. In one case gangrene of the 
extremity necessitated amputation at the hip-joint. 

It may be stated, however, that in the younger class of cases 
the operation, if conducted with reasonable regard to the resist- 
ance of the tissues and to the susceptibility of the patient, is prac- 
tically free from danger. 

In cases treated at the proper age — that is, under six years for 
bilateral and under eight for unilateral cases — about 50 per cent, 
of the unilateral and 25 per cent. (50 per cent, for each side) of 
the bilateral cases can be anatomically and functionally cured. 
Lorenz claims success in 358 of 680 cases treated, 52.6 per cent. 1 
Nearly all the others can be greatly improved, in that the pos- 
terior displacement may be converted into an anterior one. In 
such cases, in which the head of the femur is forced forward 
below the anterior superior spine, the static conditions become 
approximately normal, and further displacement is to a great 
extent prevented by the firm tissues attached at this point. A 
stable articulation is assured by long retention of the limb in the 
position of abduction and extension by means of the plaster 
bandage and by exercises and passive movements after its removal. 

As has been stated, in successful cases the head of the femur 
can always be palpated directly beneath the femoral artery. The 
first indication of failure is a slight lateral displacement of the head 
to the outer side of the artery. This may appear even during 
the period of fixation, and cases should be systematically examined 
for such failure by palpating the head of the femur beneath the 
bandage; usually, however, it is not apparent until the plaster 
bandage is removed. At first there is no shortening, but slowly, 
as the displacement increases and as the head of the bone ascends 
from the neighborhood of the acetabulum to that beside or above 
the anterior inferior pelvic spine, this becomes evident. At first 
it is half an inch, later an inch, but it is not often more than this, 
at least during childhood. 

1 American Medicine, June 18, 1904. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 539 



It has been stated that this outcome may be expected in about 
half of the favorable cases as to age in which all the details of 
the operation have been properly carried out, and it is the usual 
result in the unfavorable class. This result, which is not classed 
by Lorenz as a failure, but rather as an improvement, may be 
explained in certain instances by 
interposition of a fold of capsule be- FlG ' 343 

tween the head of the bone and the 
acetabulum, or by failure of the pro- 
cess of reformation of the acetabu- 
lum. In many cases, however, it is 
accounted for by an anterior twist 
of the upper extremity of the femur, 
so that the neck instead of pointing 
inward and slightly forward from the 
shaft is turned forward and slightly 
inward. Thus, in order to replace 
the head in the acetabulum, the limb 
must be rotated inward until the foot 
points inward rather than forward. 

Occasionally the presence of this 
deformity may be ascertained before 
operation. It may be suspected, for 
example, in nearly all the anterior 
and supracotyloid displacements in 
older subjects, and it could be de- 
monstrated, doubtless, by a series of 
Roentgen pictures. In most cases, 
however, the failure of treatment calls 
attention to the probable existence of 
the deformity. It is, of course, ap- 
parent that the only remedy is a cut- 
ting operation. Lorenz is content in 
these cases with anterior apposition, 
but if it is probable that a twist in 
the upper extremity of the femur is 
alone responsible for failure, it seems 
more reasonable to remove this by 

osteotomy. This operation will be described in connection with 
the open operation. 

The Treatment of Older Subjects. — It has been stated that the 
final result in a very large proportion of the operations was anterior 




The cure of congenital dislocation. 
The same patient is shown in Fig. 



540 OB THOPEDIC S UR GER Y 

transposition or apposition, as Lorenz calls it, and that in cases 
beyond the age of eight years this result is to be expected. In 
this class of cases — from ten to twenty-one years of age — it is 
the primary aim of the operation. After preliminary traction in 
bed and after subcutaneous division of the more resistant tendons 
if this is necessary, the limb is forced into moderate abduction 
and extreme extension, so that the head of the bone is displaced 
forward to the neighborhood of the anterior inferior spinous 
process. In this attitude the limb is retained for many months 
by means of the plaster bandage, and it is assured in the after- 
treatment by the manipulation and exercises already described. 
Although even in the most successful cases a limp persists, yet it 
is far less noticeable than in untreated cases, the discomfort is 
relieved, the limb is lengthened, and the danger of future disa- 
bility is much lessened. 

In those unusual cases in which the adduction and flexion 
deformity is extreme, osteotomy of the femur may be required, 
and if the pain is persistent excision of the hip may be necessary. 

The Treatment of Congenital Dislocation in Infancy. — At the 
present time in contrast to former years one often has the oppor- 
tunity to treat congenital dislocation in infancy and early child- 
hood. The details of treatment do not differ essentially from 
those already described, except, of course, that reduction is easily 
effected (Fig. 335) and that walking or weighting (functional use 
in other words) cannot always be utilized at once in the after- 
treatment. In this class of cases, provided the test of the sta- 
bility of the joint is satisfactory, one need not fix the limb in the 
extreme position. It is well, however, to carry the bandage below 
the knee in order to assure for a time mure complete fixation. 
The support must be renewed whenever sanitary reasons indicate 
the necessity. In many instances cure is practically assured in a 
few months. 

Variations in the Treatment. — It has been stated that the first 
indication of failure was ordinarily a slight lateral displacement 
of the head to the outer side of the femoral artery, and that this 
displacement was favored by the anteversion of the neck of the 
femur. As is well known, anteversion of moderate degree is not 
unusual in the femora of apparently normal joints. In such 
instances subluxation is prevented by the cotyloid cartilage, and 
by the normal capsule, both of which are deficient in the congenital 
dislocation. When, therefore, anteversion is suspected oris known 
to exist, or if displacement has recurred after the operation, 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 54 1 

it is well to rotate the thigh inward, so that the head of the 
femur lies slightly to the inner side of the artery, and to fix it 
in this attitude by extending the plaster bandage below the knee, 
the leg being slightly flexed upon the thigh. This attitude should 
be retained until it may be assumed that the capsule is sufficiently 
contracted to restrain the femur from reluxation. 



Fig 


344 




J^^^BjHr^ 



Axillary abduction. 

In some instances, especially in anterior displacement in young 
subjects, the upper anterior border of the acetabulum seems to offer 
no resistance to redisplacement. One may then place the limb 
in axillary abduction (Werndorff), Fig. 344, for a month or more, 
in the hope that the upper border of the capsule will contract 
sufficiently to prevent redisplacement. 

In such cases, and in fact in all cases in which the upward 
displacement is feared, the patient should be anaesthetized when 



542 



ORTHOPEDIC SURGERY 



the plaster is changed. One may then hold the head of the femur 
in place and stretch the contracted tissues, particularly the ilio- 
femoral ligament, sufficiently to permit the lessened abduction, for 
the resistance of these tissues seems in certain instances to be the 
direct cause of displacement. 

Arthrotomy. — If the Lorenz operation has failed when all the 
details have been thoroughly carried out, the advisability of an 











<%£_ 



Bilateral dislocation six months 
after replacement by the open 
method in 1897, illustrating the 
change in the contour of the trunk. 



A successful result after the open operation, 
illustrating a form of brace to be used in 
the after-treatment to hold the limb in proper 
position if it has a tendency to rotate outward. 

exploratory operation suggests itself. Under proper aseptic pre- 
cautions this should entail no danger nor should it compromise 
the functional ability of the joint. One can then assure one's 
self that the head of the bone is actually replaced within the 
acetabulum. Arthrotomy is indicated also if the resistance to 
reposition by the ordinary method is so great that dangerous 
force must be exerted to overcome it. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 543 

The joint is exposed by a lateral incision about three inches in 
length, extending downward from a point about three-quarters 
of an inch to the outer side of the anterior superior spine of the 
ilium, the fascia is divided, and the line of junction between the 
tensor vaginae femoris and the gluteus medius muscles is found. 
These muscles are then separated and are drawn to either side by 
retractors, thus exposing the capsule of the joint. This is opened 
by an incision parallel to the neck of the bone. The finger is 
then passed through the opening, down upon the rudimentary 
acetabulum. A strong cervix dilator is next inserted and the 
contracted capsule is thoroughly stretched. If the ligamentum 
teres is present it is removed. 

The head is then replaced; the capsule and overlying tissues 
are united with catgut sutures. The limb is then fixed in the 
typical position by the Lorenz spica. In the majority of cases 
the cause of the failure of the primary operation is an antever- 
sion of the neck of the femur. In this event after replacement 
the limb must be rotated inward to the required degree and fixed 
by a plaster bandage extending below the knee as a preliminary 
to osteotomy. 



Osteotomy. 

When the limb has been fixed for several months in the attitude 
of inward rotation, so that stability is in some degree assured, 
the operation for correcting the anterior twist of the upper 
extremity of the femur should be performed. 

The plaster bandage having been removed, a long drill should 
be pushed through the trochanter and into the neck of the bone 
to fix the upper fragment. A subcutaneous osteotome is then in- 
serted at a point just below the trochanter minor or at the lower 
third of the femur, and a thorough division of the bone is made. 
The lower osteotomy is perhaps to be preferred, because one has 
better control of the fragments at this point. When the division 
is complete, the upper fragment being fixed by the drill, the limb 
is rotated outward until the normal relation between the shaft 
and the neck is restored. A plaster spica including the foot is 
then applied, by which the drill and the upper fragment are fixed 
in proper relation to the shaft. Several weeks later, when the 
improved position is assured, this is withdrawn. The after-treat- 
ment is the same as in the uncomplicated cases. 



544 



ORTHOPEDIC SURGERY 



The Open Operation with Enlargement of the Acetabulum. — The 
original Hoffa-Lorenz operation, once the treatment of routine, 
is now reserved for a restricted class of cases in which the blood- 
less operation has failed, or in which on opening the joint the 
acetabulum is found to be notably deficient. 

Supposing the shortening of the limb to have been overcome 
by previous treatment, the joint and capsule are opened in the 
manner already described. One finger is then inserted to the 
acetabulum and by its side a strong, sharp bayonet-shaped spoon 




seel in the treatment of congenital dislocation, also the subcutaneous osteotome. 



(Fig. 347) is passed, and with it the shallow acetabulum is en- 
larged to a sufficient size, care being taken to accentuate its supe- 
rior and posterior border. The head is then placed within it, and 
the wound is closed or packed according to the custom of the opera- 
tor. Hoffa, who is now the principal exponent of the operation, 
makes an oblique incision from the anterior superior spine down- 
ward and backward over the trochanter and exposes the joint 
between the gluteus medius and minimus muscles. He usually 
employes the Doyen instrument and bores out a very capacious 
acetabulum. A long plaster spica is then applied with the limb 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 545 

in an attitude of moderate abduction and extension. In a month, 
or when repair is complete, a short Lorenz spica is applied and the 




Unsuccessful treatment by forcible correction (Lorenz operation). The posterior has 
been changed to an anterior displacement. Rear view. 

patient is encouraged to walk about. This support should be worn 
for from six months to a year in order to prevent the contractions 
that almost inevitably follow operations of this character. Exer- 
35 



546 ORTHOPEDIC SURGERY 

cise and forcible manipulation within a few weeks after the opera- 
tion, as recommended by many writers, are not only of no service, 
but in the author's experience, harmful. 

When the spica is removed and the patient is allowed to run 
about, motion usually returns. At this time massage should be 
employed and passive movements always in extension and abduc- 
tion. Later gymnastic training is of great value. After this 
operation, provided there is true anatomical cure, motion is 
usually restricted to a greater or less degree, and in older sub- 
jects there is often fibrous anchylosis. For this reason it should 
be limited to unilateral cases, or, at all events, one should never 
operate on the second hip until the result of the operation in 
the first is known. In unilateral cases anchylosis without de- 
formity is not a serious functional disability, as there is solid 
support without shortening; while if fair motion is obtained, as in 
many instances, the functional result is far better than after simple 
transposition. It should be stated that even after the open opera- 
tion this transposition is often the outcome. In such cases motion 
is, of course, free and the stability is somewhat greater than after 
the bloodless operation. If after this operation motion is extremely 
limited one must expect flexion and adduction deformity unless 
it be prevented by careful treatment. In certain instances the 
range of motion may be increased by breaking up adhesions and 
stretching the contracted parts under anaesthesia. 

The danger of the operation is slight, and the deaths, with 
but few exceptions, have been due to infection. Lorenz and 
Hoifa lost several of their earlier patients from this cause, but 
with improved technique the danger is slight. 1 The bad results 
of the operation may, as a rule, be accounted for by its improper 
performance, particularly the failure to replace the femur securely, 
or by failure to ensure asepsis, or by inefficient supervision and 
after-treatment. 

It is perhaps unnecessary to state that operations of this char- 
acter should not be performed unless asepsis can be assured, 
unless the operator is familiar with the anatomy of the parts, 
and unless the essential after-treatment can be provided. 

Review of the Treatment of Congenital Dislocation of the Hip. — 
The prospect of success in treatment stands in direct relation 
to the age of the patient, since the degree of the pathological 

1 Hoffa has performed the operation 248 times, with 10 deaths, 8 due to the opera- 
tion, the last 132 operations without a death. Lorenz, in 260 operations, lost 4 patients 
from septicemia. — Report of the Thirteenth International Congress, Paris, August, 1900. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 547 

changes, that make cure difficult or impossible, depends in great 
degree, as in acquired dislocations, upon the duration of the dis- 
ability. Consequently, treatment should be applied as soon as 
the displacement is discovered, and, as has been stated, there is 
little excuse for not making the correct diagnosis when the child 





Unilateral dislocation. Two years 2... £L i. Unilateral dislocation. Eighteen months after 
after operation in 1897 by the Lorenz operation by the Lorenz method in 1897. A 

method. A complete cure. complete cure. 

begins to walk. The treatment of selection is the functional 
weighting method of Lorenz, modified somewhat in certain cases 
in that the limb may be placed with advantage in that position 
which best assures stability. By this treatment a larger proportion 
of the cases may be cured, and in all instances the posterior may 
be changed into an anterior displacement, which is a great improve- 



548 



ORTHOPEDIC SURGERY 



ment. The treatment at the hands of a competent surgeon in 
properly selected cases is free from danger, for now that the strain 
that the tissues will safely withstand is better known, violent and 
prolonged manipulation has been discarded. In the older class, or 
when reduction is difficult, the resistant parts should be stretched 
by preliminary traction in bed, or the reduction should be accom- 
panied at two sittings. 




m 



Unilateral dislocation, after operation 
by the Lorenz method in 1897. A com- 
plete cure. Compare with Fig. 323. 



Unilateral dislocation, two years after 
operation. Compare with Fig. 324. 



If one is not content with functional improvement in the cases 
in which anatomical cure has not been attained the treatment 
may be supplemented by arthrotomy, and if anteversion of the 
upper extremity of the femur prevents success it may be remedied 
by osteotomy. 

Excavation of the acetabulum will often assure anatomical 
success. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 549 

Anatomical reposition with fair or even very limited motion 
assures better function in unilateral cases than transposition, but 
anchylosis with deformity is certainly no improvement on the 
original condition. It may be suggested, also, that the dangers 
of open operation even if slight must be considered. 

In the treatment of adolescent cases one should attempt to 
obtain anterior transposition and to assure it by fixing the limb 
for a sufficient time in the improved position. 

Palliative Treatment.— Palliative treatment does not require 
extended comment. In brief, in unilateral cases a cork sole may 
be worn to equalize the length of the limbs, and in bilateral cases 
a corset suitably strengthened with steel supports may be adjusted 
if the lordosis is extreme. Exercise and passive manipulation 
with the aim of retaining, as far as possible, the ability to abduct 
and to extend th ethighs may be of service in preventing secondary 
contractions. Overexertion that causes discomfort or pain should 
be avoided. 

Congenital Subluxation of the Hip. 

As has been stated, there are cases of congenital displacement 
of the hip which are in reality subluxations. In such cases there 
is a slight limp and slight shortening, and an a>ray picture shows 
a secure acetabulum somewhat above the plane of the opposite 
side. These subluxations are always of the anterior variety. 
They should be treated in the ordinary manner. 

Snapping Hip. 

Some individuals possess the power of slightly displacing the 
hip, usually upon the superior or upper border of the acetabulum. 
This is sometimes seen in infancy, the child's thigh snapping with 
a jar or even audible sound upward and downward. This is 
usually accomplished when the child is seated in the mother's 
lap, the thigh being flexed and adducted, and in this class of 
cases it is, according to the mothers, an evidence of temper. As 
the displacement may be increased by habit, it is well to restrain 
it by applying a bandage about the hip to prevent flexion of 
the limb, which is apparently preliminary to its accomplishment. 
(See Snapping Knee.) Snapping about the hip in older subjects 
is usually induced by friction between the gluteus maximus 
muscle and the trochanter. 



550 ORTHOPEDIC S UB OEB Y 



Coxa Vara. 



Synonyms. — Depression or incurvation of the neck of the 
femur; bending of the neck of the femur. 

The character of this deformity is indicated by the synonyms. 
The term coxa vara signifies that its causes and effects are similar 
to those of genu valgum and varum, the more common distor- 
tions of the lower extremities. 

Genu valgum and varum are common in childhood, but rarely 
develop in adolescence. Coxa vara is, in comparison, an infre- 
quent deformity, and it is peculiar in that it more often appears 
in later childhood or adolescence than at the earlier period, doubt- 
less because the neck of the femur is, at the age when rhachitic 
distortions are common, very short, and, therefore, relatively 
stronger than the shaft, while in adolescence the conditions may 
be reversed. 

The distortions at the knee are self-evident, but the neck of 
the femur is concealed from view; thus the diagnosis of coxa 
vara may be somewhat difficult; and, in fact, it is only in very 
recent years that its symptoms have been recognized. Fiorani 1 
first described the deformity as it had been observed by him in 
children; but E. Miiller 2 first called attention to the affection as 
one of the deformities of adolescence, which, until that time, had 
been mistaken for hip disease. 

Pathology. — The term coxa vara should not be applied to 
depression of the neck of the femur that may be secondary to 
destructive disease, for example, to osteomyelitis, arthritis de- 
formans, osteomalacia, and the like, but it should be reserved 
for cases of simple local deformity. In most instances the defor- 
mity affects the neck as a whole (cervical coxa vara); in others 
it is most marked at the epiphyseal junction (epiphyseal coxa 
vara). Epiphyseal coxa vara is more often found in the adoles- 
cent class, and particularly in those cases in which the symptoms 
have been induced or aggravated by injury or strain. Whether 
the injury caused primarily a partial epiphyseal separation which 
afterward slowly increased under the strain of functional use; or 
suddenly increased a pre-existing distortion of the weakened 
part is sometimes difficult to decide. A number of specimens 
of coxa vara have been examined, but no changes, other than 
such as might be caused by the deformity itself, have been found. 

1 Gazetta degli Ospitale, 1881, Nos. 16, 17. 
- Beitriige zur klin. Chir., 1889, Bd. iv. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 55 1 



These are, in brief, congestion and softening of the bone, and 
evidences of irritation within the joint during the progressive 
stage of the deformity, with the general adaptive changes in all 
the components of the joint that always accompany displacement 
or distortion. These may be considerable, including, in advanced 
cases, a change in the acetabulum, whose upper border^is less 
sharply defined than normal. 

Etiology. — Many writers assume that the weakness of the neck 
of the femur that predisposes to deformity is the result of local 
disease, such as so-called local 

rickets or local osteomalacia. FlG- 3o3 

This is, however, simply a con- 
venient hypothesis. Others 
believe the deformity to be 
symptomatic of late rickets, 
although evidence of general 
rhachitis is almost never pres- 
ent in the ordinary type as it 
appears in later childhood and 
adolescence. 

Coxa vara, at least of the 
ordinary type, may be classed 
as one of the group of static 
deformities of the lower ex- 
tremity caused by a dispropor- 
tion between the strength of 
the supporting structure and _ „ • . , . ., t ., , 

r r e m Section'of thejupper extremity of a norma 

the burden that is put Upon it. femur at eight years of age; angle formed by 
„„ , J . the neck with the shaft 140 degrees. In the 

1 he Support may be dlSprO- normal subject the neck of the femur projects 
r>nrti'nmtplv wppIc henniiSP of] f sli g htl y forward (12 degrees) and upward to 

portionateiy weak, Decause oil i form an angle with the ghaft of about 125 

inherited delicacy of Structure y "degrees. In childhood this angle it usually 

, , , . . somewhat greater, and in later years it may be 

it may be Weakened by injury somewhat less than 125 degrees; in fact, a 

1 i- „ „ *j. U~ ~„~™ variation between 110 and 140 degrees may be 

or by disease, or it may be over- within the normal limit-1 
burdened by weight or strain. 

Mechanical Predisposition to Deformity. — In many cases the pre- 
disposition to deformity is the result of a lessened angle of the 
femoral neck. This slight and predisposing depression, which 
appears to be, in many instances, the effect of early rhachitis, 
becomes exaggerated to deformity during later childhood or 
adolescence. In this sense — that of a remote result — coxa vara 
may be classed as one of the rhachitic deformities. The impor- 

1 Humphrey, Jour. Anat. Phys., vol. xxiii. p. 236. 




552 ORTHOPEDIC SURGERY 

tance of this mechanical factor in the etiology was demonstrated 
to me by the investigation of a number of cases of simple frac- 
ture of the neck of the femur in childhood. In these cases the 
neck of the femur was, by the original injury, somewhat depressed, 
and although immediate functional recovery followed, yet in a 
number of the cases progressive deformity, attended by the symp- 
toms of typical coxa vara, resulted. This could be explained 
only on the theory that the lessened angle, subjecting the part to 
greater strain, was the predisposing cause of the later disability. 
Other factors in the etiology may be general weakness, incident 
to rapid growth, direct injury (fracture), and the strain of occu- 
pation. 1 

1 this connection it may be stated that fracture of the neck 
of the femur in childhood may cause a deformity which in the 
absence of a history could not be distinguished from the ordinary 
form of coxa vara, of which, in fact, it is the traumatic form. 
(See Fracture of the Neck of the Femur and Epiphyseal Sepa- 
ration.) 

If the statistics are limited to the class in which the deformity 
causes distinct symptoms it will appear very decidedly as an 
affection of late childhood and adolescence. It is far more com- 
mon in males than in females and it is usually unilateral, facts that 
would seem to indicate the influence of strain or injury in inducing 
or increasing the distortion. 

The points of special interest in 72 personal cases may be sum- 
marized as follows: In about one-third of the cases there was a 
distinct history of rhachitis in infancy. The ages of the patients 
were as follows: 

Adolescents, twelve to seventeen 40 

La' er childhood, five to eleven 23 

Early childhood, less than five 3 

Over seventeen years 6 

Total 72 

In many instances the symptoms had persisted for a long time, 
even many years, before the patients came under observation; 
but taking this fact into account it may be stated that in more 
than half the cases the deformity did not appear until adolescence 
and that at least three-fourths of the patients were beyond the period 
of early childhood when the ordinary rhachitic distortions of the 

1 Several cases of congenital coxa vara have been reported. In such instances the 
deformity is often one of many distortions. Depression of the neck of the femur in con- 
genital dislocation of the hip has been mentioned in the section on that affection. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 553 

limbs are most common. 46 of the patients were males, 26 were 
females. In 59 cases the deformity was unilateral, 32 of the right 
and 27 of the left side; in 13 it was bilateral. In the majority of the 
cases the neck of the femur was distorted in a direction backward 
and downward ; in perhaps 10 either directly downward or down- 
ward and forward. Many of the patients were observed before 
the a>ray was available for diagnosis, but it is estimated that in 
about one-fourth of the adolescent cases the distortion was greatest 
in the vicinity of the head of the bone (epiphyseal coxa vara) ; in 
the others the neck of the femur as a whole was involved (cervical 
coxa vara). 

Symptoms. 1. Mechanical Effects. — The character of the 
symptoms may be explained by a description of the distortion and 
of its direct effects upon the function of the joint. When the 
neck of the femur is depressed, for example, to a right angle with 
the shaft, the trochanter is elevated to a corresponding degree 
above Nekton's line, and forms a noticeable projection as con- 
trasted with the normal contour (Fig. 357), a projection that 
becomes more marked when the thigh is flexed and adducted 
(Fig. 356). In most instances the neck is displaced backward 
as well as downward, following the line of least resistance, and 
as the head of the bone remains in the acetabulum the trochanter 
is thrown forward and the limb is rotated outward. The ability 
to abduct the thigh is dependent upon the upward inclination of 
the femoral neck (Fig. 195); when, therefore this inclination is 
diminished the range of abduction is lessened, in part by the 
greater tension that is exerted upon the lower portion of the cap- 
sule, in part by the direct contact of the rim of the acetabulum 
with the neck and trochanter (Fig. 354), and in part by the adap- 
tive contractions that always accompany distortions of this 
character. It is evident, also, that the deformity of the neck 
backward and downward changes the relation of the acetabulum 
to the head of the femur, so that abduction or flexion tends to 
displace it from its socket. Thus the range of abduction, of 
inward rotation, and of flexion is limited, while that of adduction, 
outward rotation, and extension may be increased. 

There is actual shortening of the limb dependent upon the 
upward displacement of the shaft of the femur. This is not often 
more than an inch in the ordinary type of adolescent deformity, 
but the apparent shortening, caused by the adduction and the 
accommodative upward tilting of the pelvis, may be extreme; 
from two to three inches is not uncommon (Fig. 357). 



554 



OB THOPEDIC SUEOEBY 



2. Physical Effects. — The symptoms of coxa vara of the ordinary 
type are discomfort, awkwardness, limp, shortening, atrophy, 
limitation of motion, deformity. 

Coxa vara is a more disabling deformity than genu varum or 
valgum, and its attendant symptoms of discomfort, weakness/ 
and pain are, as a rule, more marked. This is explained by the 
fact that in coxa vara the head of the bone is in part displaced 
from the acetabulum (Fig. 355), while in the deformities at the 
knee the joint surfaces remain in practically normal relation to 
one another. 

Fig. 354 




Skiagram of coxa vara; deformity most marked at the epiphyseal junction. This illus- 
trates the mechanical limitation of abduction caused by the deformity, and the compensa- 
tory tilting of the pelvis. The patient is shown in Fig. 357. 

The symptoms of unilateral coxa vara vary with the degree 
and with the duration of the deformity. The patient usually 
complains of sensations of stiffness and weakness, referred to the 
thigh. These are more noticeable on changing from a position 
of rest to one of activity, and at times, particularly after over- 
exertion, there may be actual pain. By far the most important 
symptom and the one that almost always induces the patient to 
seek treatment is the limp. This limp, accompanied, as it usually 
is, by outward rotation of the foot, resembles that caused by 
united fracture of the neck of the femur. On physical exami- 
nation the actual shortening, explained by the elevated and 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 555 

prominent trochanter and the peculiar unequal limitation of motion, 
will make the diagnosis clear. In some instances there may be 
a marked degree of muscular spasm, and there is usually mod- 
erate atrophy of the muscles of the thigh. 

Bilateral Coxa Vara. — If the deformity is bilateral its effect 
upon the gait and attitude is more marked. The gait is extremely 
awkward, resembling somewhat that of knock-knees, for the 
limitation of abduction forces the patient to sway the body from 
side to side in order that the knees may not interfere; and if 
the deformity is extreme the limbs may be crossed over one another, 




/.„_ 



Cross-section of the pelvis and the deformed femur. A scheme to show the effect of the 
deformity in limiting abduction of the limb. The dotted outline shows the normal relation. 

so that locomotion may be difficult. In the ordinary form of 
bilateral coxa vara the femoral neck on each side is displaced 
backward as well as downward, and as the head of the femur 
remains in the acetabulum the shaft is thrown forward, so that 
the trochanter is nearer the anterior superior spine than is normal. 
This displacement of the support lessens the inclination of the 
pelvis and consequently the normal lumbar lordosis. Bilateral coxa 
vara is not infrequently accompanied by other deformities, as, 
for example, knock-knee or flat-foot (Fig. 358). 



556 ORTHOPEDIC SURGERY 

Other Varieties of Coxa Vara. — Far less often the neck of 
the femur may be depressed directly downward or even down- 
ward and forward. In the latter instance the effect of the de- 
formity upon the function of the joint is somewhat different 
from that of the ordinary type. Abduction is limited, as in the 
common form, but inward rotation replaces outward rotation, 
and extension is limited in place of flexion. This type of deformity 
is almost always bilateral. It is accompanied, usually, by slight 
permanent flexion of the thighs; thus the lumbar lordosis is exag- 
gerated; whereas, in the ordinary form it is usually lessened. 

This description applies to the ordinary types of the deformity 
as it is seen in later childhood and in adolescence. It undoubt- 
edly occurs in early life, but it is masked by the more noticeable 
distortions of other parts, and as an isolated deformity that de- 
mands treatment it is uncommon. One case was observed by 
the writer in a rhachitic child two and one-half years of age. 
The symptoms, though slight, were typical, and the diagnosis 
was confirmed by a Roentgen picture. In other cases seen in 
later childhood, the history of more or less discomfort for many 
years seemed to indicate that the deformity was caused directly by 
rhachitis, and as has been stated the slighter degrees of deformity, 
usually bilateral, may be demonstrated on careful examination 
in a considerable proportion of rhachitic children, particularly 
in those presenting the deformity of knock-knee. 

In the majority of cases the symptoms begin insidiously, 
although, in many instances, they may follow injury or over- 
exertion. (See Partial Epiphyseal Separation.) If the affection 
begins in adolescence and is untreated, the period of discomfort, 
during which the depression of the neck may be assumed to be 
progressive, is from two to four years; but if the deformity appears 
at an early age, the symptoms, though remittent in character, 
may continue indefinitely. When the resistance of the compressed 
bone becomes sufficient to ensure stability the discomfort ceases, 
and the disability becomes less marked, as nature accommodates 
the mechanism to the new conditions. 

Diagnosis. — In most instances diagnosis may be easily made, 
and yet coxa vara is very often mistaken for hip disease; in fact, 
we are indebted to this mistake for most of the specimens of the 
deformity that have been described. The essential differences 
between the two are as follows: In tuberculous disease of the 
hip the motions of the joint are limited in every direction by 
reflex muscular spasm, and, as a rule, other evidences of the 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 557 

character of the disease are apparent. Coxa vara is a simple 
deformity; reflex muscular spasm is absent, except during exacer- 
bations due to injury or overstrain, and movement is not limited 
in all directions, but only in abduction, flexion, and inward rota- 




Coxa vara, showing the prominent trochanter. 



Illustrating the tilting of the 
pelvis and the apparent short- 
ening of the limb in unilateral 
coxa vara. Actual shortening, 
three-fourths of an inch; ap- 
parent shortening, two and a 
half inches. The deformity of 
the epiphyseal type was ap- 
parently induced by overexer- 
tion. (See skiagram, Fig. 354.) 



tion when the deformity is of the ordinary type. Actual shortening 
is a late symptom of hip disease, while it is present from the very 
onset of coxa vara. It is a shortening explained by the elevation 
of the trochanter above Nelaton's line, while such elevation in 
hip disease is a sign of destruction either of the head of the bone 
or of a part of the acetabulum. 



558 



ORTHOPEDIC SURGERY 



The deformity might be readily mistaken for congenital dislo- 
cation of the hip, particularly of the anterior variety, but this 
would be excluded by the history, since coxa vara is an acquired 
deformity. The diagnosis between the two affections may be 
easily made on the physical signs alone. In congenital disloca- 
tion, if the thigh be flexed and adducted to its extreme limit, the 
head and neck of the displaced bone can be distinguished beneath 
the distended tissues of the buttock. In coxa vara nothing but 
the prominent trochanter can be made out on similar manipula- 
tion, while the abnormal mobility, characteristic of the dislocation, 




Double coxa vara of advanced degree, showing the involuntary crossing of 
the limbs in flexion. 

is absent. There is, however, a form of anterior dislocation in 
which the head of the femur has a secure support beneath the 
anterior superior spine in which diagnosis from the physical signs 
alone may be somewhat more difficult. An x-ray picture will 
always make the distinction clear, however. 

Treatment — If the deformity were discovered in the early stage, 
one might hope to check its progress by a change in the surround- 
ings and occupation of the patient. Standing, particularly in 
the attitude of rest, which throws additional weight upon the 
weakened part, should be avoided, and work of any kind that 
induces J;he familiar symptoms of strain should be discontinued. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 559 

As much time as possible should be spent in the open air, and 
diet and proper therapeutical remedies should be employed if 
evidence of constitutional weakness or rhachitis is present. 

Locally, massage of the limbs and joints and forcible manipula- 
tion, with the aim of overcoming as much of the restriction of the 



Fig. 








Unilateral coxa vara, showing the effect of 
slight depression of the neck of the left femur 
upon the attitude. (See Fig. 360.) 

range of abduction as may depend 
upon the secondary changes in the 
soft parts, should be employed, 
reinforced by regular gymnastic 
exercises, with the object of im- 
proving the circulation, upon which 
the repair of the weakened bone 
depends. 

If the deformity is unilateral temporary support may be in- 
dicated. A perineal crutch (Fig. 251) or, if the circumstances 
of the patient permit, one of the convalescent hip splints that 



The patient, Fig. 359, eight months 
after cuneiform osteotomy. An abso- 
lute cure, both as regards symptoms 
and deformity. 



560 ORTHOPEDIC SURGERY 

permits motion at the knee, may be used (Fig. 252). With sup- 
port during the time of greatest strain — that is, when continuous 
walking or standing may be acquired — combined with proper 
exercises and massage, the weak part may become sufficiently 
strong to perform its function in a year or more, but supervision 
will be necessary for a much longer time. 

Operative Treatment. Forcible Abduction. — In certain instances 
particularly those cases in adolescence in which the symptoms 
have advanced rapidly, it may be inferred that the bony structure 
of the affected neck is congested and softened. One may attempt, 
therefore, to restore the angle by forcibly abducting the thigh, as 
in the treatment of fracture or epiphyseal separation. (See page 
565.) In this manoeuvre the head is fixed by the lower portion 
of the capsule, and the deformed neck is forced against the upper 
border of the acetabulum as illustrated in the diagrams (Fig. 362). 
If the normal range of abduction can be restored, one may infer 
that the deformity has been corrected. The limb should then be 
fixed by a plaster spica bandage in this attitude of extreme abduc- 
tion for two months, or until a time when consolidation in the new 
position is apparently complete. 

A support should be used for a time, and the usual treatment 
by massage and exercise should be carried out during the period 
of convalescence. 

Linear Osteotomy. — The simplest and most efficient means of 
overcoming the distortion in older subjects is linear osteotomy of 
the shaft of the femur just below the trochanter minor. This 
may be performed by the subcutaneous method, as in the correc- 
tion of the deformity of hip disease. When the bone has been 
divided the shaft is rotated inward to the proper degree, and it 
is then abducted to the normal limit; in this attitude a plaster 
spica bandage is applied reaching from the axilla to the toes. 

If the deformity is bilateral it is often sufficient to operate on 
the limb which is most affected. When the fracture is consolidated, 
massage, exercises, and manipulation are employed, as has been 
described. It may be assumed that the increased blood supply 
necessitated by the repair of the injury will affect favorably the 
weakened bone as well. The final result in several cases, in which 
the operation was performed by the writer, was very satisfactory. 

Cuneiform Osteotomy. — In younger patients, unless the outward 
rotation is marked, the deformity should be remedied by remval 
of a cuneiform section of bone from the upper extremity of 
the shaft at the level of the trochanter minor (Fig. 361). In 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 561 

childhood the neck of the femur is short and the strain to which 
it is likely to be subjected slight; thus operative treatment may 
be indicated as a prophylactic measure. In fact, one should treat 
this deformity at the hip on the same principles as the similar 
distortions at the knee. Coxa vara cannot be rectified by mechan- 
ical treatment; therefore, unless it is directly contraindicated 
operative intervention should be advised. 

In the technique of this procedure there are several points of 
importance. First, the restriction of abduction, of ligamentous 
or muscular origin, must be overcome by vigorous stretching and 
massage of the shortened tissues before the operation on the bone, 
otherwise it will be difficult to bring the two fragments into proper 
apposition. An incision is made from a point about one inch 
below the apex of the trochanter directly downward about three 
inches in length. The bone is thoroughly exposed by separating 
the periosteum from the site of operation. The base of the 
wedge should be about three-quarters of an inch in breadth, 
directly opposite the trochanter minor; the upper section should 
be practically at a right angle with the shaft, the lower being 
more oblique (Fig. 361, 2)'. The cortical substance on the inner 
aspect of the bone should not be divided, but, reinforced by the 
cartilaginous trochanter minor, should serve as a hinge on which 
the shaft of the femur is gently forced outward, until the opening 
is closed by the apposition of the fragments after the upper seg- 
ment has been fixed by contact with the margin of the acetabulum 
(Fig. 361, 3); thus the continuity of the bone is preserved. The 
limb is then fixed in the attitude of normal abduction by means of 
a plaster spica bandage, which should include the foot also, for 
about eight weeks, or until the union is firm. When the limb is 
brought to the line of the body the neck of the femur is restored 
to its proper position (Fig. 361, 4). This mechanical method of 
apposing the fragments is far more effective than any system of 
suture. If the operation is carefully conducted there can be no 
danger of displacement, and in this there is a manifest advantage 
over a simple osteotomy. In ordinary cases of this class, accord- 
ing to the writer's experience, the cure is absolute, both as to 
symptoms and to function. No after-treatment other than the 
support of a short Lorenz spica for a month or more is required. 

The opportunity for treatment of coxa vara in earliest childhood 
is rarely offered. It is usually the direct result of rhachitis, and 
in the early stage at least it is probably accompanied by other 
rhachitic distortions. It would be well, therefore, to examine 

36 



562 



OR TH 0PED1 C SURGERY 



the hip-joints of rhachitic children, especially those who present 
the deformity of genu valgum with reference to this distortion. 

Fracture of the Neck of the Femur. 

Traumatic Coxa Vara. — Fracture of the neck of the femur in 
childhood, although until recently unrecognized, is by no means 
an uncommon accident, since 35 cases have come under the 
writer's observation during the past 16 years. 





1. The normal femur. 2. Depression of the neck of the femur — coxa vara. A. A wedge of 
bone has been removed. 3. Abduction of the limb first fixes the upper segment by contact 
with the rim of the acetabulum, then closes the opening in the bone. 4. Replacement of 
the limb after union is completed elevates the neck to its former position. 

Fracture of the neck of the femur in childhood, however, differs 
markedly in its symptoms and in its effects from that in later 
life. Although it may be complete, it is usually partial, what may 
be termed the "green stick" variety. Thus, the immediate effects 
of the injury are far usually less disabling, and the patient is often 
able to walk about within a few days after the accident. During 
the period of repair the limp and attendant discomfort are usually 
mistaken for symptoms of hip disease. 

The diagnosis is not difficult. There is a history of injury, 
usually a fall from a height which confined the patient to the 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 563 

bed for several days or weeks. On physical examination shorten- 
ing of half an inch to an inch is found, explained by the corre- 
sponding elevation of the trochanter. Motion in the joint is 
more or less restrained by voluntary and involuntary contrac- 
tion of the muscles, but this restriction is much more marked in 
flexion, abduction, and inward rotation than in other directions; a 
limitation explained by the nature of the displacement, the neck 
of the bone having been forced downward and backward. 

The immediate effect of the injury is, as has been stated, less 
marked than in the adult, but the deformity often tends to increase 




1. Fracture of the neck of the femur. 2. Restoration of the normal angle by forcible 
abduction. 3. The limb in normal position. 4, 5, and 6 illustrate separation of the 
epiphysis of the head of the femur treated by the same method. 

in later years, because the right-angled relation of the neck to the 
shaft exposes it to greater strain. In a number of the patients 
examined several years after the injury there was an increase 
of the actual shortening combined with permanent adduction. 
At this time the deformity could not have been distinguished, 
except for the history, from the ordinary coxa vara of a rather 
extreme degree. 

Treatment. — If the diagnosis is made immediately or before 
consolidation is complete, one should attempt to replace the neck. 



564 OB THOPEDIC S UR GEE Y 

in its proper relation with the shaft in order to restore normal 
function and to prevent subsequent disability. This may be 
accomplished by forcing the limb to the limit of normal abduction, 
under anaesthesia, thus utilizing the fulcrum of the upper border 
of the acetabulum to restore the normal angle of the neck. In 
this position a plaster bandage, reaching from the axilla to the 
toes, should be applied (Fig. 365). 

After consolidation of the fracture a hip splint or Lorenz spica 
may be used for several months or until complete repair has 
taken place. Massage and forcible manipulation, if limitation of 
motion remains, combined with the avoidance of overstrain, should 
restore function and prevent the increase of the deformity. 

After consolidation the untreated fracture is practically a form 
of coxa vara. In such cases the neck of the femur should be 
replaced in its normal position by the removal of a sufficient wedge 
of bone from the base of the trochanter as described under the 
treatment of simple coxa vara (Fig. 361). 

Traumatic Separation of the Epiphysis of the Head of the Femur. — 
As has been stated, in traumatic depression of the neck of the 
femur the fracture is usually at about the centre of the neck, 
which in childhood is but little more than an inch in length. 
In other instances the head of the femur may be partially or 
completely separated at or near the epiphyseal line. This dis- 
junction is more likely to occur in adolescence and particularly 
in subjects suffering from coxa vara in the early stage. Thus 
sudden disability, following slight injury, in an adolescent who 
has complained of discomfort and limp for some time before, 
and who presents on examination the signs of depression of the 
neck of the femur, should suggest this accident; but the exact 
diagnosis can be established only by a Roentgen picture or by 
operation. 1 

The treatment is similar to that of fracture, but the functional 
derangement of the joint is likely to be greater for the reason that 
the articulating surface of the head of the femur is involved. 2 If 
disturbance of function is due directly to the deformity the joint 
should be opened by the anterolateral incision. The partly dis- 
placed head may then be completely separated by a thin chisel 
and replaced in proper position, or, if the deformity is slight, 
the irregularities that interfere with motion may be removed. 

1 Sprengel, Archiv f. klin. Chir., 1898, B. xlvii., S. 805. Clarke, Lancet, October 27, 1900. 
- Whitman, Medical Record, July 25, 1893; Annals of Surgery, June, 1897, February, 
1899, and November, 1902. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 565 

Partial Epiphyseal Separation in Adolescence. — As has been sug- 
gested, slight injury may, under favoring conditions, rupture the 
periosteum and the cortical substance at the junction of the 
epiphysis and the neck of the femur, and under the strain of use 
the head of the bone may be slowly depressed, the final result 
being the epiphyseal type of coxa vara that has been described. 
The symptoms of this variety of deformity, which is practically 
limited to adolescence, resemble those of ordinary coxa vara, 
except that they are more marked and more disabling. 

In other cases the displacement may be greater or practically 
complete, in which case the disability is immediate, although the 
traumatism was apparently very slight. This accident under these 
conditions is very unusual in healthy children. Particular atten- 
tion is called to this point, as the two classes of cases are 
usually confounded, traumatic depression of the neck of the 
femur being classed, as a rule, as epiphyseal separation. 1 The 
treatment has been described in the preceding section. 

Fracture of the Neck of the Femur in Adult Life. — The treatment 
by forcible abduction and fixation recommended for incomplete 
fracture of the neck of the femur or epiphyseal separation in 
childhood, with the aim of restoring symmetry, applies also to the 
so-called impacted fracture in older subjects. 

The patient having been anaesthetized is placed upon a box of 
sufficient size, about seven inches in height, the pelvis resting on a 
sacral support and the extended limbs held by assistants. That on 
the sound side is then abducted to the normal limit to demonstrate 
the range and to fix the pelvis. That on the injured side is 
then under traction slowly abducted, the surgeon supporting 
the joint with his hands and pressing the trochanter gently down- 
ward. The limitation of abduction, caused by contact of the 
neck with the deformed border of the acetabulum, is recognized, 
but it is easily overcome. When the limit of normal abduction is . 
reached it may be inferred that the proper relation between the 
neck and shaft of the femur has been restored. The limb is then 
securely fixed in this attitude by a long plaster spica until repair 
is sufficiently advanced (Fig. 365). 

If the fracture is complete the same treatment is adopted with 
the following modification. The patient lying in the position 
described with the sound limb abducted the disabled member 
is flexed to disengage folds of capsule that may have fallen between 

1 Whitman, Med. News, September 24. 1904. 



566 



ORTHOPEDIC SURGERY 

Fig. 363 




Impacted fracture of the neck of the right femur, illustrating the reduction of the defor- 
mity by direct traction and abduction. The operator supports the joint. The left limb 
is abducted to indicate the normal range, which varies in different subjects, and to prevent 
tilting of the pelvis. 




A. Complete fracture of the neck of the femur, illustrating the influence of the muscles 
in increasing the displacement. B. Complete fracture, after reduction and fixation in the 
position of abduction, illustrating the security assured by the direct contact of the tro- 
chanter with the side of the pelvis; also the tension on the capsule and'the removal of the 
deforming influence of the muscles. 



CONGENITAL DISLOCATION OF HIP AND COXA VARA 567 

the fragments. It is then extended and rotated to the normal 
attitude and under traction and counter-traction the shortening 
is completely overcome, as demonstrated by measurement. The 
limb is then slowly abducted by the assistant while the surgeon 
supporting the joint pushes the thigh upward from beneath to 
force the two fragments against the anterior part of the capsule. 
When the limit of abduction has been reached the capsule will 
be tense, thus directing the fragments toward one another, the 
trochanter will be apposed to the side of the pelvis, thus preventing 
upward displacement and the tension of the muscles, which favors 





Fig. 


365 














1 












Eddfi t ' 


* 




» — 4H&& i 






SK&LuJl 


W< •■ MUk tmt^. 


- 









The long spica as applied for the treatment of fracture of the neck of the femur in the 
adult at an angle of abduction of 45 degrees 

deformity, will be completely relaxed. A plaster spica is then 
applied, as in the preceding instance. In the after-treatment the 
support of a modified hip splint (Fig. 252) is desirable, and func- 
tional recovery will be hastened by massage and by appropriate 
pressure and active exercises. 

One often encounters cases in which the disability persists after 
fracture of the neck of the femur — a disability due in great part 
to flexion and adduction deformity. Such deformity may be, in 
many instances, reduced by moderate force. If, as is often the 
case, the fracture has failed to unite and the open operation is 



568 ORTHOPEDIC SURGERY 

impracticable the upper extremity of the femur may be forced 
forward beneath the anterior superior spine and the limb may be 
fixed in an attitude of abduction and extension by a short spica, 
as originally suggested by Lorenz. 1 

Coxa Valga. 

Coxa valga is a term used to signify an abnormal elevation of 
the neck of the femur in its relation to the shaft, in contrast to 
coxa vara, an abnormal depression. This deformity is sometimes 
observed in limbs which have never supported weight. It is a 
possible result of injury also. It is of no particular importance 
from the orthopedic standpoint. 

1 The author's method of treating fracture of the neck of the femur is described in 
detail in the Amer. Jour, of Med. Sci., July, 1905. The Medical Record, March 19, 1904. 
The Therapeutic Gazette, May, 1906. 



CHAPTER XVI. 

DEFORMITIES OF THE BONES OF THE LOWER EXTREMITY. 

Of the distortions of the lower extremity bow-leg and knock- 
knee are by far the most common, comprising about 15 per cent, 
of the total cases in orthopedic clinics. Of the two, bow-leg is 
the more frequent in all tables of statistics, and it is probable 
that the proportion of bow-leg to knock-knee is much larger than 
would appear from the hospital records; for genu valgum is 
generally recognized as a serious deformity, while bow-leg is 
known to be of little consequence except from the aesthetic stand- 
point, so that its rectification is more often trusted to the power 
of nature. 

Both deformities appear to be more common in male than in 
female children — a fact explained, perhaps, by the greater weight 
and the greater susceptibility of the former. But here, again, 
statistics may be influenced somewhat by the fact that bow-leg 
is considered to be of more consequence to the boy than to the 
girl, because of the concealment that the skirts will ensure if the 
distortion is not outgrown in childhood. 

Statistics. — The relative frequency of the two deformities may 
be indicated by the statistics of the Hospital for Ruptured 
and Crippled for a period of 15 years, 1899-1904. During this 
time 8760 cases were recorded, 5741 cases of bow-leg (65.5 per 
cent.), 3019 of knock-knee (34.5 per cent.). Of the 5741 cases 
of bow-leg 3401 were in males (59 per cent.) and 2340 were 
in females (41 per cent.). The 3019 cases of knock-knee were 
more evenly divided between the sexes, 1601 being in males 
(50.04 per cent.) and 1409 in females (49.06 per cent.). 

It will be noted that 94 of the cases of genu valgum were in 
patients over fourteen years of age, as compared with 78 cases 
of adolescent or adult bow-leg. The writer's personal expe- 
rience in the clinic enables him to state that a large proportion of 
the cases of genu valgum actually developed or increased to an 
extent demanding treatment during adolescence, while most 
of the cases of bow-leg deformity in patients more than fourteen 



570 OB THOPEDIC S UR OEB Y 

years of age had existed since early childhood or were the result 
of injury or disease. 

The Etiology of Genu Valgum, Genu Varum, and of Other 
Distortions of the Bones of the Lower Extremity. — The com- 
mon predisposing cause of simple deformities and disabilities of 
the lower extremities — in other words, those not caused by local 
injury or local disease — is the erect posture, when for any reason 
the bones and the joints are unequal to the strain of locomotion 
and to the task of sustaining the weight of the body. 

Time of Onset. — At two periods of life the deformities under 
consideration most often develop. The first is in early childhood, 
when the upright posture is first assumed; the second is in adoles- 
cence, when the rapid growth and other changes incident to this 
period may lessen the stability of the supporting structures, and 
when the strain of laborious occupation may be added to that of 
the increasing weight of the body. 

The deformities of adolescence are, however, relatively insig- 
nificant in number compared with those of early childhood, for in 
childhood inherited weakness or weakness that is the direct 
result of malnutrition at once develops into deformity under the 
strain of standing and walking. Thus, as a rule, the deformities 
under consideration first attract attention soon after the child 
begins to walk. If the deformities are severe the body usually 
presents the evidences of general rhachitis; in other instances the 
distortion of the legs is almost the only sign of its presence, and 
in a certain number there may be no evidence whatever of malnu- 
trition or disease. 

Predisposition to Deformity. — It is not always easy to explain why 
weak legs bend in one way rather than in another. In many 
instances it may be assumed that a slight degree of deformity is 
present before the child begins to walk. For example, a slight out- 
ward bowing of the legs is not uncommon in early infancy, and the 
use of heavy diapers might favor an increase of the distortion. 
Knock-knee may be induced, apparently, by holding the infant 
on the arm with the knees pressed against the chest, and certain 
cases of knock-knee and bow-leg combined appear to be caused 
directly by this manner of carrying the infant habitually upon 
one arm. 

The legs of rhachitic children who have never walked are often 
somewhat distorted and in many instances this may be explained 
by the habitual postures (Fig. 366). 

A moderate degree of bow-leg is not infrequently seen in vigorous 



DEFORMITIES OF BONES OF LOWER EXTREMITY 571 

infants who stand and walk at an early age. Aside from the 
determining curve in the bone that may be present before the 
child begins to walk, this predisposition toward bow-leg may 
be explained, perhaps, by the fact that young infants often separate 
the feet widely in walking, and the swaying of the body from side 
to side may tend to bend the legs outward. In weaker or less 
vigorous children a slight degree of knock-knee is not uncommon, 
induced more directly by weakness or inactivity of the muscles, 




Habitual posture 



factor in the etiology of rhachitic bow- 



as a result of which the child stands with the knees somewhat 
flexed and pressed together, while the feet are separated and 
everted, an exaggeration of the so-called attitude of rest. 

Bow-leg is not uncommon in adult life, and it is popularly 
associated with strength and activity. Undoubtedly the attitudes 
of activity would tend to induce bow-leg rather than knock- 
knee, so that this tradition may have a foundation of truth. It 
is said to be common among those who ride constantly, and it 



572 ORTHOPEDIC SURGERY 

may be a direct result of injury or disease of the knee-joint, but 
it may be stated that well-marked bow-leg in an adult has almost 
always existed since childhood. This statement cannot be made 
of genu valgum, since it may develop or increase during ado- 
lescence or even in adult life. The predisposing cause is weak- 
ness or overstrain, and, as has been stated, in the popular mind 
the deformity is characteristic of weakness. 

The Attitude of Rest. — Genu valgum is an exaggeration of 
what is known as the attitude of rest or relaxation, in which the 
weight of the body is thrown in great part upon the ligaments of 
the three joints of the lower extremity. In the attitude of rest 
the pelvis is tilted forward, the femora are rotated inward upon the 
tibiae, and the feet are separated and everted, so that the greatest 
strain falls upon the inner side of the knees and of the feet. Thus, 
what is known as flat-foot is often combined with knock-knee. 
Knock-knee may cause flat-foot, but more often the flat-foot 
may induce knock-knee, or both may be the effect of the same 
general cause. Genu valgum, in the slighter degree at least, 
may be induced directly by improper attitudes; but the attitudes 
are, as a rule, the result of overwork to which the mechanism is 
subjected; thus the knock-knee of adolescence is so common 
among the bakers of Vienna that "baker's knee" is there synony- 
mous with genu valgum. 

Genu valgum may be secondary to distortion elsewhere. For 
example, compensatory knock-knee is usually combined with 
extreme adduction of the thigh; it may be the result of the in- 
activity necessitated by the treatment of hip disease; it may be 
a direct result of injury, and it is sometimes an accompaniment 
of osteomyelitis or osteoperiostitis of the tibia, which causes an 
overgrowth and abnormal lengthening of the leg. These are, 
however, exceptional cases that should not be classed with the 
ordinary deformity. 

The Outgrowth of Deformity. — In considering the treatment of 
the simple static deformities of the lower extremity, which are 
usually the result of a temporary weakness of structure, one must 
first answer the question, "Will not the child outgrow it?" This 
belief in the spontaneous cure of deformity is very strong, 
not only among the laity, but among physicians as well; and it 
rests upon the common observation that crooked legs become 
straight, or at least less deformed, with the growth of the child. 
In fact, if one were to judge from the general observation of the 
effect of growth upon the deformities of this class, or even from 



DEFORMITIES OF BONES OF LOWER EXTREMITY 573 

the tracings of the legs of rhachitic children taken from year to 
year, one might conclude that all deformities of this class might 
be safely left to themselves. As an illustration of positive evi- 
dence on the subject, the observations of Kamps 1 on 32 cases of 
rhachitic distortion of the lower extremity may be cited. Four 
and one-half years after the cases were first seen and recorded 
examination showed that 75 per cent, were cured, 15.3 per cent, 
improved, while 9.7 per cent, were unimproved. His conclu- 
sions are that such deformities do not, as a rule, require special 
treatment in early childhood, but that after the age of six years 
the prognosis for spontaneous cure is unfavorable. 

Veit 2 photographed a number of rhachitic children seen in the 
surgical clinic of the University of Berlin, and after a lapse of 
two or three years made another series of photographs of the 
same patients, who had meanwhile received no treatment. His 
conclusions are similar to those of Kamps, namely, that surgical 
treatment is not required for deformity of this character in chil- 
dren less than six years of age. In two classes of cases, however, 
the prognosis for spontaneous cure is not favorable, those in 
which the growth has been checked by the rhachitic process, and 
in certain cases of extreme bow-leg, "O" legs (Fig. 367). 

The rectifying force of nature acts in two ways. Assuming 
that the deformity reached its limit during the period of original 
weakness, it must, of course, become relatively less as the body 
increases in length and size. In fact, the outgrowth of deformity 
has a direct relation to the rapidity of growth during the 
early years of childhood. It must be borne in mind also that 
not infrequently rhachitic bones are bent in two or more direc- 
tions so that knock-knee and bow-leg may be combined in the 
same person. One may, therefore, outgrow the bow-leg while 
the knock-knee persists or in time becomes less noticeable. The 
second manifestation of the power of nature is more positive. 
It may be assumed that when the deformity is progressive all the 
tissues are affected by the weakness; consequently the attitudes 
of the child are those that can be most easily assumed under the 
abnormal conditions. But when the primary cause of the weak- 
ness, in most instances rhachitis, is no longer operative, the muscles 
take on new activity and vigor, and the actions and attitudes, 
in spite of the deformity, become approximately normal. Then, 
according to Wolff's law of transformation, the internal structure 

1 Beitrage zur klin. Chir., B. xiv., H. 1. 
s Archiv f. klin Chir., B. 1., S. 130. 



574 



ORTHOPEDIC SURGERY 



of the affected bones begins to change to accommodate itself to 
the new conditions of weight and strain induced by the change 
in action and attitude; and to this rearrangement of the internal 
structure the external shape of the bones must conform in a gradual 
growth toward the normal contour. 

On this theory it is easily explained how the natural outdoor 
life of the country has long been celebrated as an effective treat- 
ment for this class of deformity. But it by no means follows 
that deformity is always outgrown even under favorable condi- 
tions. Improper attitudes that favor and cause deformity are 

often observed among those who 
are free from weakness and dis- 
ability and from the influences 
of unfavorable surroundings ; 
and such attitudes are, of course, 
more likely to persist in those 
who were once obliged to assume 
them because of weakness and 
deformity. Again the weakness 
of structure or function may be 
an inherited peculiarity, or it may 
be induced by disease or by im- 
proper surroundings, influences 
that may continue for many 
years and thus serve to check the 
natural tendency toward cure. 
The observations on the out- 
growth of deformity have been 
confined, as a rule, to the period 
of childhood, and most often they 
have been made with reference 
to the more serious grades of distortion, which are the direct result 
of rhachitis. It must be borne in mind, however, that the true 
significance of these deformities in the adult must be judged from 
the aesthetic rather than from the medical point of view, and although 
the extreme degrees of bow-leg and knock-knee are relatively rare, 
yet in the minor grade both deformities are very common in adult 
males and in all probability in adult females also. 

In 1887 the writer 1 noted among 2000 adult males observed 
on the streets of Boston, 400 cases of bow-leg and 32 cases of 
knock-knee. One may assume, then, that the legs of about one 




A type of deformity in 
as regards outgr 



'hich the prognosis 
iwth is bad. 



New York Medical Record, July 30, 1S87 



DEFORMITIES OF BONES OF LOWER EXTREMITY 575 

adult male in five deviate more or less from the line of symmetry — 
a conclusion that has been confirmed by many subsequent observa- 
tions. It may be admitted that a certain number of the distortions 
under consideration are acquired during adolescence, but it is 
probable that the greater number of those that may be noted in 
walkers upon the streets represent the incomplete outgrowth of a 
deformity of childhood. 

The statement is often made that these distortions of the legs 
are common in childhood but rare in adult life. Just what the 




Extreme deformities, the result of infantile rhachitis. The left leg forms practically 
a right angle with the thigh. (See Fig. 372). 

proportion may be in childhood it is impossible to say, but it is 
not likely to be greater than one in five. One must conclude 
that statistics, on which such statements are based, have been 
made up from the records of hospitals where it is extremely uncom- 
mon for an adult to apply for the treatment of bow-leg, to which 
he has become accustomed since childhood, unless the deformity 
is extreme or is attended by pain. 



576 



ORTHOPEDIC SURGERY 



Granting that the power of nature is quite sufficient to modify 
or to cure even the more extreme distortions of childhood, still 
it is evident that this natural force is often ineffective in com- 
pleting the cure. Therefore, in doubtful cases at least, one should 
lend assistance in that class of patients likely to appreciate the 
advantage of symmetry over deformity, even though it be unat- 
tended by discomfort or disability. 

Genu Valgum. 

Synonyms. — Knock-knee, in-knee. 

In the erect posture the thighs, whose upper extremities are 
separated by the pelvis and by the projecting femoral necks, 





Female. Male. 

The normal inclination of the femora. (Pfeiffer.) 

incline slightly inward to the knees, forming an angle at the 
knee, opening outward, of about 172 degrees. This angle varies 
with the breadth of the pelvis, and it is, therefore, less in adult 
females than in males (Figs. 369 and 370). The internal condyle 
of the femur is slightly longer than the external; thus the inclina- 
tion of the femur is compensated and the plane of the knee-joint 
is horizontal. 

When the inward projection of the knees is increased to a 
noticeable degree the tibia? are no longer perpendicular; their 
upper extremities incline inward so that in the erect posture 
the feet are separated when the knees are in contact (Fig. 371). 
In the slighter grades of knock-knee, which are due in great degree 



DEFORMITIES OF BONES OF LOWER EXTREMITY 577 

to laxity of the ligaments, the deformity is apparent only when 
the weight of the body is borne, but in more marked cases, although 
the distortion is increased by the weight of the body, it cannot 
be overcome when this is removed, because it depends upon 
actual changes in the shape of the bones themselves. 

As has been stated, the normal inward inclination of the femur 
is compensated by the greater length of the internal condyle, and 




Adolescent knock-knee. Deformity most marked in the tibiae 



Fig. 374.) 



in the deformity of knock-knee the plane of the knee-joint is 
still preserved by an apparent elongation of the inner condyle. 
Formerly it was supposed that there was an actual overgrowth 
of this part of the epiphysis which caused the deformity, but the 
observations of Mikulicz and Macewen have shown that this 
apparent lengthening is in reality due in great part to a deformity 
of the lower extremity of the shaft of the femur, which is so bent 
that the epiphyseal line has an increased obliquity. And the 

37 



578 OB TH OPE DIC SURGERY 

hypothesis that bone grows more rapidly when relieved from 
weight and strain has been disproved by Wolff, who has demon- 
strated that changes in the bones are the result of accommodation 
to altered function and attitude. (See page 238). The deformity 
is not limited to the femur; in most instances there is a similar, 
although usually slighter, irregularity in the epiphyseal line of 
the upper extremity of the tibia, the shaft being so bent that 
when it is placed in the perpendicular position its internal con- 
dylar surface is higher than the external. In some instances the 
primary and principal deformity is of the shaft of the tibia, the 
distortion being most marked in its upper third (Fig. 371). 

Changed Relation of the Femur and Tibia. — In addition to the 
direct deformities of the bones there is a change in the relation 
of the femur to the tibia. The former is rotated inward and the 
latter is rotated outward. In some instances there is also a cer- 
tain degree of overextension at the knee. This is more often 
observed in the adolescent type, in which there is laxity of the 
ligaments (Fig. 371). In the ordinary form of rhachitic knock- 
knee in childhood the habitual attitude is one of slight flexion 
at the knees, and in extreme cases there may be actual limitation 
of the range of extension at the knee, and at the hip as well. 

The Accommodative Attitude. — When the limb is fully extended 
the deformity is most marked, because the shortened ligaments 
and tissues on the outer aspect of the joint become tense, and 
because the outward rotation of the tibia is increased. As the 
leg is flexed the deformity lessens, and in the attitude of complete 
flexion it disappears (Fig. 374). This is explained by the fact 
that the posterior surface of the condyles is not affected by the 
deformity of the shaft, while the relaxation of the ligaments and 
the outward rotation of the femora allow the tibia? to become 
parallel with one another. This accounts for the habitual attitude 
of slight flexion which is so often assumed by patients who thus 
unconsciously accommodate themselves to the deformity. 

Secondary Deformities. — The outward inclination of the leg 
throws more weight upon the inner border of the foot and tends 
to depress it into the attitude of valgus. Thus knock-knee in 
weak children is often accompanied by flat-foot, but in the more 
extreme grades of deformity the efforts of the patient to com- 
pensate for the abnormal separation of the feet may result in 
habitual inversion; in fact, comfirmed and extreme knock- 
knee in older subjects is usually accompanied by a slight degree 
of varus that becomes very evident after the correction of the 



DEFORMITIES OF B ONES OF LO WEB EXTBEMIT Y 579 

deformity by operation. Even in the mildest type of knock- 
knee this compensatory and conservative effort of nature is shown 
by the so-called pigeon-toed walk, which is often the first symp- 
tom that attracts attention. 

Gait. — The gait of the patient with well-marked genu valgum 
is peculiarly awkward and shambling. The knees "interfere" 
and must be assisted, as it were, in the effort to pass one another 




Skiagram of Fig. 368, showing the deformity to be due to distortions of the diaphyses 
of the bones, while the epiphyses are practically normal. 



in walking. In the slighter cases the thigh is abducted and rotated 
outward at the moment of passing its fellow, the movement being 
then reversed as it, in its turn, supports the weight; but in the more 
severe type this voluntary effort of the muscles of the leg is not 
sufficient, and, in addition, the body is swayed from side to side 
and the legs are alternately swung outward and lifted around one 
another. 



580 



ORTHOPEDIC SURGERY 



The deformity and the effects of the deformity on the gait and 
attitude are the most important symptoms, as of other distortions 
of similar origin. The patient is, as a rule, easily fatigued, and 
pain during the progressive stage, referred to the inner side of 
the knee, where the ligaments are subjected to continuous strain 

is a common symptom, particu- 
FlG - 373 larly in the adolescent type of 

genu valgum. 

Unilateral Knock-knee. — This 
description refers particularly to 
the cases in which the deformity 
is bilateral. Not infrequently it 
is unilateral, the limb being so 
shortened by the distortion that 
a well-marked limp replaces the 
swaying gait. The pelvis is tilted 
toward the short limb, while the 
body is inclined in the opposite 
direction, thus in cases of long 
standing a permanent curvature 
of the lumbar spine may be 
present. 

Knock-knee Combined with Bow- 
leg and with General Rhachitic 
Distortions. — Occasionally the 
unilateral knock-knee may be 
accompanied by an outward 
bowing of its fellow; and in the 
marked distortions of the lower 
extremity, induced by rhachitis, 
the bones may be twisted and 
bent in various directions, al- 
though the outward expression 
of the deformity may be genu 
valgum. For example, the femora may be bent forward and 
outward above and inward and backward below, while the tibiae 
may be bent inward above and outward and forward below. 

In other instances, especially in the slighter rhachitic deformi- 
ties, an outward bowing of the leg may accompany a slight degree 
of knock-knee, so that it may be difficult to classify the deformity. 
In the more extreme deformities of the rhachitic type the 
shape as well as the contour of the bones is markedly modified, for 




Deformity of the femur in genu valgum. 
(Mikulicz.) 



DEFORMITIES OF BONES OF LOWER EXTREMITY 581 

example, the internal border of the tibia may become very prom- 
inent at its upper extremity, and may project beneath the skin 
like an exostosis (Fig. 375). A change in the contour of the 
fibula accompanies and corresponds to that of the tibia, although 
it is, as a rule, much less pronounced. As has been stated, the 
internal structure or architecture of the affected bones is changed 
to accommodate the new static conditions, and according to 
Wolff the internal change precedes the external deformity. 

Pathology. — In knock-knee due directly to rhachitis the changes 
in the bones and in the epiphyseal cartilages are characteristic 
of that affection, but in the milder grades of deformity, aside 




Adolescent knock-knee, showing the disappearance of the deformity when legs are flexed 
(See Fig. 371.) 

from the change in the contour of the bones, the transformation 
of the internal structure, and in some instances slight thickening 
or irregularity of the epiphyseal cartilages, there is little note- 
worthy change from the normal (Fig. 373). The tissues on the 
internal aspect of the joint are relaxed; those on the outer side, 
the lateral ligaments, the capsule, and the biceps muscle, are con- 
tracted and resist the reduction of the deformity. In the interior 
of the joint slight changes in the articulating surfaces of the bones 
and evidences of chronic irritation of the synovial membrane 
have been described. 

Measurements. — There are various methods of measuring the 
deformity. One of the simplest and most practical is to trace 



582 



OR THOPEDIC S UB GEE T 



the outlines on paper, while the child is seated with the limbs 
fully extended, the knees being sufficiently separated to allow 
the pencil to pass between them. The increase of the deformity, 
depending upon the laxity of the ligaments and upon the outward 
rotation of the tibiae, may be estimated by measuring the distance 
between the two internal malleoli when the patient stands, the 




Knock-knee and bow-leg. 

knees being slightly separated as before, and comparing this 
measurement with that between the similar points in the tracing. 
In the early stage of progressive knock-knee, particularly in 
the type not caused directly by rhachitis, laxity of ligaments and 
the habitual assumption of the attitude of rest will account for 
the deformity, which the patient may be able to overcome, in 



DEFORMITIES OF BONES OF LOWER EXTREMITY 583 

great degree at least, by voluntary effort. This voluntary control 
of the deformity is very suggestive, as indicating certain factors 
in its etiology, and the principles that should be followed in its 
treatment. 

Treatment. — The treatment of the deformity under considera- 
tion may be classified as expectant, mechanical, and operative. 

Expectant Treatment should not be expectant in the sense that 
nothing is done to correct the deformity, but expectant in that 
more positive treatment by braces or by operation is delayed or 
avoided if it proves to be unnecessary. 

During this period the predisposing cause of the deformity, if 
it is constitutional, should receive proper dietetic or medicinal 
treatment, as already described in the chapter on Rhachitis. 
And, if possible, the direct exciting causes of the deformity must 
be removed — that is to say, the improper attitudes, or, in the 
adolescent, the predisposing occupations should be discontinued. 
General massage of the limbs may be employed with advantage; 
in older children special exercises may be practised, and in all 
cases, whether braces are used or not, direct manipulation of the 
distorted limbs is of the first importance. 

Manipulation. — The limbs should be vigorously massaged at 
morning and night, and forcibly straightened. The latter pro- 
cedure is conducted as follows: The patient is seated in a chair, 
the limb being fully extended so that the deformity is made as 
extreme as possible. One hand then clasps the knee, the palm 
lying against its inner aspect; with the other the calf is grasped 
firmly and the leg is then gently straightened over the fulcrum 
formed by the palm of the hand, and is held in the corrected 
position for a moment. This manipulation should be continued 
with gradually increasing force, although not to the extent of 
causing actual pain, for ten minutes at least twice in the day and 
oftener if possible. 

Posture and Exercise. — It has been stated that genu valgum is 
often accompanied, especially in the rhachitic cases, by flat-foot, 
while in another type the inversion of the feet, or in the more 
severe cases the actual fixed attitude of varus, indicates the effort 
of nature to withstand and to compensate for the deformity at 
the knee. This serves as an indication for making the soles of 
the shoes thicker on the inner border, as in the treatment of flat- 
foot, in order to throw the strain upon the outer border of the 
foot. The patient should be instructed to walk with the feet 
parallel with one another, and for older children the tip-toe exer- 



584 



ORTHOPEDIC SURGERY 



cises, in which the body is raised upon the toes as many times 
as the strength permits, or games or exercises in which the legs 
are extended should be encouraged. Such exercises are often 
efficacious in the early stage of adolescent knock-knee, for, as 
has been mentioned, genu valgum is an exaggeration of the 
attitude of rest; therefore, its progress should be checked by the 




The Thomas knock-knee brace. 



Thomas knock-knee braces with pelvic band. The 
pelvic band may be divided also, the two parts being 
joined by straps (Fig. 378). 



assumption of the attitudes proper to activity. Bicycle riding, and 
particularly horseback riding may be recommended also in this 
class of cases. A careful record of the deformity should be kept 
during this tentative treatment, and if it improves somewhat one 
is justified in delaying the more radical measures. This question 
may be decided, as a rule, in three months if instructions are 
faithfully followed. 



DEFORMITIES OF BONES OF LOWER EXTREMITY 585 

Treatment by Braces, — The most efficient brace for the treatment 
of genu valgum is the simple straight steel bar or splint extend- 
ing from the trochanter to the heel of the shoe, without joint at 
the knee. The greater efficacy of the rigid bar as compared with 
the jointed brace is explained by the fact that the rectifying force 
acts constantly when the joint is fixed, and because, in many 

Fig. 378 




Modified Thomas knock-knee braces applied. 



instances, the patient habitually flexes the knees so that direct 
pressure cannot be made upon the deformity by a brace that 
permits this attitude. 

The Thomas Brace. — The simplest and cheapest brace is 
that of Thomas, which consists of a light steel bar provided with 
a pad at its upper end for pressure against the trochanter, while 
the lower, rounded extremity is turned inward at a right angle, 



586 



ORTHOPEDIC S UE QER Y 




to pass through the heel of the shoe. The knee is fixed by a 
posterior bar attached to a thigh and calf band, as illustrated in 
the figure. When the brace is applied the knee is drawn back- 
ward and outward and is attached firmly to the brace by a roller 
bandage (Fig. 376). 

In the more extreme cases in which the knees and thighs are 
habitually flexed, the addition of a pelvic band attached to the 
uprights by a free joint at the hips adds to the comfort and effi- 
ciency of the apparatus, as the attitude of outward or inward 
rotation can be regulated by twisting the uprights slightly. Or 
preferably the pelvic band may be divided and attached by means 
of straps on the front and back. The uprights may be bent some- 
what inward at first, and as the legs become straighter they are 

straightened and finally bent 
slightly outward to allow for the 
over-correction of the deformity 
(Fig. 378). Twice a day the 
braces should be removed for 
massage, manipulation, and for 
voluntary exercises of the limbs. 
In most cases the braces are not 
employed at night, although the 
rectification of the deformity may 
be hastened by their constant use. 
If the deformity is unilateral 
so that a brace is required for 
one imb only, the other shoe 
should be raised by a cork sole 
about three-quarters of an inch 
in thickness, to make walking 
easier. Children soon become 
accustomed to the braces and " 
walk easily in spite of the ab- 
sence of joints at the knees. 

Another simple and efficient 
brace is that used at the Chil- 
dren's Hospital at Boston (Fig. 
379). The upper part of the 
brace is turned backward and upward to lie against the buttock, 
and the feet can be rotated in or out by lengthening or shortening 
straps passing before and behind the body. Braces jointed at the 
knee are sometimes employed, but they are, as a rule, ineffective, 





Long braces for genu valgum. 
(Bradford and Lovett.) 



DEFORMITIES OF BONES OF LOWER EXTREMITY 587 

except in the slighter cases in which the deformity depends upon 
laxity of ligaments rather than distortion of bone. 

Duration of Treatment by Braces. — The duration of the 
brace treatment depends, of course, upon the degree of deformity, 
the age of the child, and upon the efficiency of the apparatus. 
From six months to one year of treatment by this means is 
usually required. The cure is assured by the gradual adaptation 
of the parts to the new static conditions. The contracted tissues 
of the outer aspect of the joint become lengthened; the lax liga- 
ments on the inner side contract; the internal structure of the 
condyles and of the adjoining diaphysis is gradually transformed 
and at the external contour of the bone becomes correspondingly 
straighter. When the braces are discarded attention should be 
paid to the attitudes, and the exercises that have been mentioned 
should be continued in order that relapse may be prevented. 

The Plaster Bandage. — When the bones are yielding, as 
in young children, it may be corrected rapidly by the repeated 
applications of plaster bandages, the limbs being straightened as 
far as possible without causing discomfort at each sitting, or it 
may be corrected at once by manual force under anaesthesia, 
which is the better method. 

Operative Treatment. — Immediate correction of the deformity, 
when it is at all marked, is, as a rule, indicated after the age of 
four or five years, and is a satisfactory treatment at any age except 
during the period of active rhachitis. It is perhaps needless to 
remark that the necessity for operation implies neglect of proper 
preventive treatment or the failure of the manipulative and me- 
chanical methods, because of their improper application. While 
it is possible to correct deformity of the bones by mechanical 
treatment in cases far beyond this limit of age, yet the time required 
and the discomforts of the treatment exclude it in all but very 
exceptional cases. 

Osteotomy. — During a period of five years 176 cases of knock- 
knee were operated on at the Hospital for Ruptured and Crippled ; 
17 per cent, of the cases under in-treatment. The usual opera- 
tion was osteotomy by means of the small Vance osteotome, the 
so-called "subcutaneous osteotomy." In a certain proportion of 
the cases the bones of the thigh and leg are equally involved in 
the deformity. In others the tibia is the more distorted, but in 
most instances the correction of the deformity of the femur will 
practically restore the normal contour (Fig. 347). 

The limb having been prepared in the usual manner is semi- 



588 ORTHOPEDIC SURGERY 

flexed, and the inner surface of the knee is placed on a firm sand- 
bag. With the fingers the femur is firmly grasped just above the 
condyles, so that its size and position may be accurately deter- 
mined, and the sharp osteotome about the size of a lead-pencil is 
forced with its cutting edge parallel to the axis of the thigh down 
to the bone, at a point about one and a half inches above the exter- 
nal tuberosity. While it is held firmly in position against the bone 
it is turned to the transverse direction and is then driven through 
the cortex. When it enters the medullary canal, as is made 
evident by the lessened resistance, it is partly withdrawn and 
moved slightly to one side and the other, and driven through the 
cortical substance until by gentle force the bone may be fractured. 




The Grattan osteoclast. 

The osteotome is then withdrawn; the minute wound is covered 
with a pad of dry gauze, or, if the oozing is profuse, it may be 
closed with a catgut suture. The deformity is then overcorrected 
sufficiently to simulate well-marked genu varum, and a plaster 
spica bandage is applied. If the deformity is bilateral both limbs 
are operated upon at the same sitting. 

The plaster bandage is continued for from four to six weeks, 
and it is then usually supplemented by a brace, which may be 
worn with advantage for several months, because of the laxity 
of the ligaments of the knee-joint, which usually accompanies 
extreme deformity of rhachitic origin. In less marked cases and 
in older subjects the support is unnecessary. Massage and exer- 
cises during the stage of recovery should be employed if possible. 

Incomplete osteotomy and fracture in the manner described 



DEFORMITIES OF BONES OF LOWER EXTREMITY 589 

have been employed at the Hospital for Ruptured and Crippled in 
a very large number of cases without an unfavorable result. 
The discomfort is insignificant, and confinement to the bed after 
the third day is unnecessary. 

Cuneiform Osteotomy. — In the more extreme cases of gen- 
eral rhachitic deformity of the lower extremity in which the 
tibia is implicated, it is sometimes advisable, in addition to the 
osteotomy of the femur, to remove a cuneiform section of bone 
from the inner side of the tibia just below the epiphysis, in order 
to straighten the leg completely. In such cases it is better to 
perform the second operation at a later time, in order that the 
effect of the femoral osteotomy may be observed. In exceptional 
cases the deformity may be practically confined to the tibia; in 
such instances it should be corrected by a primary cuneiform or 
linear osteotomy. 

Osteoclasis. — Osteoclasis, by means of the Grattan osteoclast, 
is an effective operation. With this instrument the bone may be 
broken above the condyles at the desired point. The lower 
resistant bar is applied over the external condyle, the upper 
about four inches higher. The limb is then firmly fixed by tli3 
hands of an assistant, and the breaking bar is screwed rapidly 
home, breaking or bending the bone at the point of election. 
The deformity is then overcorrected in the manner described. 
Not infrequently in rhachitic cases the principal or primary dis- 
tortion is of the tibia. In such cases the correction is made at 
this point. If it is necessary to operate upon both the femur 
and the tibia the osteoclast, which bends and breaks, is to be 
preferred to osteotomy. 

The adolescent type of genu valgum is not often extreme. 
As a rule, the deformity of the bone is of comparatively short 
duration, and it is accompanied by considerable laxity of liga- 
ments. In the more chronic cases the osteotomy above the 
condyles may be performed in the manner described. 

Wolff's treatment of gradual correction by plaster-of-Paris 
bandages ("Etappen Verband") and Lorenz's method of epiphyseal 
separation described in former editions have been omitted as offer- 
ing no advantage over osteotomy or osteoclasis. 

It may be noted that paralysis due to injury of the peroneal 
nerve may follow the correction of knock-knee. In a total of 
1863 operations by osteoclasis reported by Codivilla 1 there are 34 
instances of the paralysis, 2 of which were permanent. 

1 Zeits. f. Orth. Chir. 



590 



OR THOPEDIC SURGERY 



Genu Varum. 



Synonym. — Bow-leg. 

The term bow-leg includes, in its popular sense, all the dis- 
tortions that cause a separation of the knees when the ankles are 
in contact with one another. But, strictly speaking, genu varum 



Fig. 382 




The genu varum type of bow-leg, showing the 
outward rotation of the femora. 



The same patient, showing the separation of 
the malleoli when the knees are in contact. 



is the reverse of genu valgum — that is, the principal distortion is 
at or near the knee-joint — while bow-leg, as the name implies, is 
a simple bowing of the tibia and fibula, as a rule near the anlde 
joint (Fig. 381). In true genu varum a line dropped from the 
head of the femur falls inside the knee (Fig. 367) ; the inner condyle 



DEFORMITIES OF BONES OF LOWER EXTREMITY 591 

of the femur and the inner tuberosity of the tibia bear the greater 
part of the weight; the outer condyle is on the same level or some- 
what lower than the internal, and the outer tuberosity of the 
tibia may be somewhat higher than the internal. The femur 
is abducted and rotated outward; the tibia is rotated inward. 
These changes, it will be noted, are the reverse of those found in 
genu valgum. As has been stated, the deformity of genu valgum 
disappears on flexion, and in genu varum, if the limbs are flexed 
and the knees are placed in contact with one another, the malleoli 
may be actually separated, simulating the deformity of knock-knee 
(Fig. 382). This is explained by the inward rotation of the 
femora, necessitated by placing the knees in contact with one 
another. 

In genu varum the distortion of the bones is not as strictly 
confined to the neighborhood of the knee-joint as in genu valgum, 
and in simple bow-leg there is almost always a certain degree of 
distortion at the knee, dependent, in part, upon laxity of the 
ligaments. It is proper, therefore, to use the two terms synony- 
mously, although one must recognize a decided difference between 
the genu varum type, in which the deformity is greatest at the 
knee, and which is accompanied, as a rule, by marked laxity 
of the ligaments (Fig. 367), and the bow-leg type, in which the 
deformity may be limited to the lower third of the leg (Fig. 388). 

Symptoms. — As was said of genu valgum, the deformity is 
the principal symptom. The gait is somewhat rolling, because 
each foot must describe a part of the arc of a circle before reach- 
ing the ground; and because of the inward rotation of the tibia?, 
or because of the inward spiral twist of the bone that is some- 
times present, patients often toe-in in walking. 

Except in extreme cases the weakness and awkwardness char- 
acteristic of genu valgum are absent. This may be explained by 
the fact that the relation of the bones is such that the general 
attitude is one of activity, the weight falling on the outer side of 
the feet; thus the weak foot is uncommon as an accompaniment 
of bow-leg, except in the early or rhachitic type or as a compensa- 
tory deformity in older subjects. 

Measurements. — The full effect of the deformity appears only 
when the weight of the body is borne, but for practical purposes 
the tracing of the extended legs is the best method of recording the 
fixed deformity. In true genu varum the deformity is greatest 
at the knee, and in the distortion the apposed surfaces of the 
femur and of the tibia participate. 



592 



ORTHOPEDIC SURGERY 



In simple bow-leg the deformity may be confined to the tibia, 
which, in addition to the outward bowing, may be twisted inward 
somewhat upon its long axis. 

Genu varum may be unilateral or it may be combined with 
genu valgum of its fellow (Fig. 375), and occasionally slight 
knock-knee and slight bow-leg may be present in the same limb. 

Treatment. Expectant Treatment. — The slighter cases of bow- 
leg in early childhood may be treated by manipulation. The 
leg, grasped firmly at the ankle and at the knee, is straightened 




Genu varum of rhachitic origin in an adult. 

with a certain amount of force over and over again. Gradual 
correction by this means may be hastened by making the sole 
of the shoe slightly thicker on the outer border. This aids also 
in correcting the secondary pigeon-toe, but if the foot is weak, as it 
usually is in rhachitic cases, this method should not be employed, 
as it might induce flat-foot. 

Treatment by Braces. — If the deformity is more extreme, or if 
improvement does not follow expectant treatment, apparatus 
should be employed. If the distortion is confined to the lower 



DEFORMITIES OF BONES OF LOWER EXTREMITY 



593 



third of the tibia a Knight brace may be used. It consists of 
two uprights attached to a foot-plate; the inner bar is provided 
with a pad at its upper end for pressure on the internal condyle 
of the femur. The outer bar reaches to the head of the fibula, 
and the two are joined by a calf band (Fig. 385). When'applied 
the leg is drawn toward the inner upright by means of a lacing, 
which passes about it within the outer 
bar. When the lacing is made 'fast, 
the outer bar is adjusted to the con- 
tour of the leg, and thus it aids 
somewhat in supporting it in an 
improved position. The foot-plate 
may be dispensed with, and the brace 
may be attached to the shoe, and even 
the outer bar may be removed, leaving 
only the upright, which is held in 
position by the lacing. The appa- 
ratus, then, has the appearance of a 
gaiter, and has the advantage of being 
inconspicuous, although somewhat 
less effective than the Knight brace. 
If the support is supplemented by 
vigorous manipulation the deformity 
may be corrected, in young children, 
in about six months. 

If the outward bowing of the knee 
is marked another form of apparatus 
will be necessary, and its effective- 
ness will be much increased if there 
is no joint at the knee. The inner bar reaches to the upper third 
of the thigh. An inner straight bar extends to the upper third of 
the thigh, and is attached to the outer bar by a thigh band. This 
inner upright is provided with a lacing of leather or canvas, similar 
to that of the short brace, which surrounds the knee and upper 
part of the leg, and thus draws it toward an improved position. 
(Fig. 385). 

Another form of brace is used at the Boston Children's Hos- 
pital, in which the upper part of the upright is curved upward 
and outward just below the groin, to a point on a level with and 
behind the trochanter, and is attached to its fellow by means of 
a strap passing across the buttocks so that the feet may be some- 
what rotated outward if necessary (Fig. 384). 

38 




Long braces for genu varum. 
(Bradford and Lovett.) 



594 



OB THO PEDIC S UB GEB Y 



Operative Treatment. — In children more than four years of 
age, and in cases of the more extreme type at an earlier age, or 
when the opportunity for mechanical treatment is lacking, or if 
rapid cure is desired, operative correction of the deformity is indi- 
cated. Either osteoclasis or osteotomy may be employed, and 
in some instances manual force is sufficient for the correction of 
the deformity. There is but little choice between the methods. 
Osteoclasis is somewhat safer possibly, and is to be preferred for 
the younger patients. 

At the Hospital for Ruptured and Crippled during a period of five 
years, of 126 patients, but 5.5 of the cases of bow-leg recorded in 



Fig. 385 




» .^- 




Mai 



The long and short bow-leg brace. 

the out-door department were admitted for operation. Osteotomy 
is usually performed. The small osteotome is inserted on the 
inner aspect of the tibia at the point of greatest deformity, and 
when the bone has been sufficiently weakened the fracture is 
completed by manual force. The fibula may be broken at the 
same time, or, as is usually the case, it may be simply bent out- 
ward. The deformity is overcorrected, and a well-fitting plaster 
bandage, including the foot and extending to the trochanter, is 
applied. 



DEFORMITIES OF BONES OF LOWER EXTREMITY 595 



The patient usually remains in bed for a few days; he is then 
dressed, and if he so desires is allowed to stand. Almost no pain 
or discomfort follows the operation, and in fact, in properly 
selected cases, it is not only free from danger, but it has a very 
decided advantage over the ordinary mechanical treatment. If the 
child is in good condition, and if the deformity is overcorrected 
at the time of operation, apparatus will not be required in the 
after-treatment; but in many instances some form of support is 
indicated, usually because slight deformity, due to laxity of liga- 
ments or to deformity of the femur, appears when the weight of 
the body falls upon the legs. 

It has been stated that the deformity of bow-legs depends in 
part upon a distortion of the femur as well as of the tibia. As a 
rule, the correction of the 
greater deformity of the tibia 
will be sufficient, but in more 
extreme cases a secondary 
osteotomy above the con- 
dyles will be necessary. This 
may be performed simul- 
taneously with that on the 
tibia, but it is better to defer 
it until the effect of the pri- 
mary operation has been 
observed. 

Anterior Bow-leg. 




Anterior bow-leg. 



Synonym. — Anterior cur- 
vature of the tibia. 

Both bow-leg and knock-knee are often seen in children who 
present no signs of general rhachitis, but anterior bowing of the 
legs is almost always combined with general rhachitic distortions. 
of the lower extremity, most often with knock-knee. These in 
turn are caused by marked distortion of the femora, which may 
be bent forward and outward above, and inward at their lower 
extremities, "corkscrew deformity." In anterior bow-leg the tibiae 
are usually flattened from side to side, curved inward or outward 
and bent forward, the projecting crests presenting sharply beneath 
the skin. 

Symptoms. — The effect of the anterior bowing is to throw the 
weight forward upon the foot; thus the heels appear abnormally 




Long anterior curvature of the tibia and flat-foot. 
Fig. 388 




fthachitic anterior bow-leg. 



DEFORMITIES OF BONES OF LOWER EXTREMITY 597 

long and prominent, and the patient seems to sink forward at 
each step (Fig. 386). The knees are usually somewhat flexed, 
partly as the effect of knock-knee, with which the deformity is 
usually combined, and the feet are, as a rule, flat. As has been 
stated, anterior bowing is almost never seen as an independent 
deformity unless it is a relic of the more general distortion which 
has been "outgrown." 

Treatment. — Anterior curvature of the tibia must, as a rule, 
be treated by operation. After complete fracture of the tibia 
and fibula the deformity may be overcome by forcing the bones 
directly backward. In many instances tenotomy of the tendo 
Achillis may be required. Cuneiform osteotomy of the tibia 
permits more perfect correction, but the final result is equally 
good after simple osteotomy or osteoclasis, and if one succeeds in 
separating the posterior part of the tibia so that it may conform 
to the straightened anterior border an actual elongation may be 
obtained. 

General Rhacbitic Distortions. 

General rhachitic distortions of the lower limbs have been 
mentioned in connection with knock-knee and with anterior 
bow-leg. A more extended description is hardly necessary. The 
deformities are usually of the knock-knee type, and they may be 
treated on the same general plan that has been outlined in the 
description of the less extreme distortions. 



CHAPTER XVII. 

DISEASES OF THE NERVOUS SYSTEM. 

From the orthopedic standpoint only those diseases that directly 
interfere with the function of locomotion or that cause deformity 
and for which local treatment is of benefit are of special interest. 
Even this limited class is not often seen in the early or progressive 
stage, and it is rather with the effects of a disease that is no longer 
present than with the disease itself that the orthopedic surgeon 
is especially concerned. 

The relative importance of this branch of orthopedic work may 
be illustrated by the statistics of the Hospital for Ruptured and 
Crippled. In a period of ten years 42,124 new patients were 
examined in the out-patient department. Excluding cases that 
cannot properly be classed as orthopedic, 38,419 remain. In 
2441 of these the nervous system was involved (6.3 percent.); 
2028 of the cases were in young children; 413 of the patients were 
more than fourteen years of age, and of this number 266 were 
adults. 

Anterior poliomyelitis furnished about 75 per cent, of the 
total number. In 20 per cent, the cerebrum was involved, and 
5 per cent, were miscellaneous cases. In 611 cases treated in a 
period of about two years there were 463 cases of poliomyelitis, 
121 cases of paralysis of cerebral origin, 16 cases of obstetrical 
paralysis, 4 cases of pseudohypertrophic muscular paralysis, and 
7 miscellaneous cases. These statistics will explain the selection 
of diseases of the nervous system for consideration and the order 
in which they are described. 

Acute Anterior Poliomyelitis. 

Synonym. — Infantile paralysis. 

Pathology. — Anterior poliomyelitis is an acute inflammatory 
process affecting the gray matter of the anterior cornua supplied 
by the anterior spinal arteries. It involves both the neuroglia 
and the cells, and it results in degeneration and atrophy of the 
interstitial tissue and of the ganglion cells. 1 

1 Starr, Loomis and Thompson's System of Practical Medicine. 



DISEASES OF THE NERVOUS SYSTEM 



599 



In the acute febrile form, comprising about three-fourths of 
the cases, there is an actual inflammation; in the other type in 
which the paralysis is of sudden onset, unaccompanied by consti- 
tutional evidences of disease, the symptoms may be caused by 
hemorrhage or by thrombosis. 

The minute changes in the cord are characteristic of inflamma- 
tion, distended bloodvessels, minute hemorrhages, infiltrating 
leukocytes, and serum. In the early stage the motor cells become 
•cloudy in appearance, later they are swollen and lose their distinct 
outlines. The degenerative changes affect both the cells and 
neuroglia; the affected gray matter shrinks and the nerve fibres 
atrophy, and the cord becomes distinctly smaller at the seat of 
the disease. When the motor conductivity of the cells is cut off, 
the muscles which are supplied by them are paralyzed and waste 
away. The circulation in the affected parts is impaired, con- 
tractions and distortions appear, and growth is retarded. 

Etiology. — The etiology of the disease is obscure. Exposure to 
heat, sudden chilling of the body, overfatigue, injury and the like 
are thought to be predisposing causes. The direct cause of inflam- 
matory disease of the cord is supposed to be some form of infection. 

The disease affects the sexes in nearly equal numbers, and those 
in perfect health as often as those whose resistance is enfeebled. 
It sometimes occurs in epidemics, and there are instances in which 
several members of the same family have been affected, but 
usually the cases are isolated and no adequate cause for the 
disease can be assigned. 

Age. — Acute anterior poliomyelitis is essentially a disease of 
infancy. This is illustrated by the combined statistics of several 
observers tabulated by Starr. 1 













ti \ u 






^ 


^ 






g 






















0J 


CD 




CLP 


<u 


<K 
















•" 












_. 


v< 


CO 




S3 


S3 


■a 


S3 


S3 


S3 




■"' 


3 


lO 


to 


" 




oa 


o 


Seeligmullcr 


. 20 


25 


18 1 


1 


2 














Cialbrnilli .... 


17 


38 


15 4 


1 

















Sinkler .... 


44 


!>2 


55 20 


1) 


2 


3 


6 





3 


(Sowers .... 


21 


21 


25 <) 


17 


4 


2 


6 


4 





Starr 


16 


38 


27 9 


10 


4 


2 


2 


4 


3 




118 


214 


140 52 


. | ,2 


' 


14 


8 


6 






472, or 77 per cent 


, before the 


fourth 


year. 







It is far more common during the warm months than at other 
seasons, as is illustrated in 452 cases tabulated by Starr. 2 

1 Loomis and Thompson's System of Practical Medicine. 2 Loc. cit. 



600 ORTHOPEDIC SURGERY 

Januiry 8 

February 5 

March 20 

April 9 

May 18 

June 49^ 327, or 72 per cent., 

July 97 I during the four 

August 116 [ months, June to 

September 65 J September. 

October 42 

November 11 

December 12 

452 

Distribution of the Paralysis. — The lower extremities are far 
more often paralyzed than the upper. In 416 of 595 cases, 
tabulated by Starr, the paralysis was limited to the lower extrem- 
ities, as contrasted with 53 cases in which the upper extremities 
were alone involved. 

Duchenne. Seeligmuller . Sinkler. Starr. Total. 

Both legs 9 14 107 40 170 

Right leg 25 15 63 20 123 

Left leg 7 27 62 27 123 

Right arm .... 5 9 5 7 26 

Left arm 5 4 8 4 21 

Both arms .... 2 1 1 2 6 

All extremities ... 5 2 35 5 47 

Arm and leg s ime side .1 2 26 4 33 

Arm and leg oppo. sides. 2 1 14 8 

Trunk 1 22 3 26 

Three extremities . . 10 2 12 

62 75 340 118 595 

Symptoms. — The disease usually is divided into several stages: 

1. The stage of onset. This is usually attended by constitu- 
tional symptoms, by fever and headache, even by convulsions 
and delirium; by vomiting and intestinal disturbance, and occa- 
sionally by severe pain. In most instances the elevation of the 
temperature is not extreme, nor is the constitutional disturbance 
severe, and but for the paralysis the attack would be considered 
• as one of the ordinary illnesses so common in childhood. In some 
cases, however, the fever is high, and there may be convulsions 
and prolonged unconsciousness, while in others there may be no 
premonitory symptoms whatever; the child, apparently well at 
night, wakens in the morning paralyzed. 

In many instances the weakness or paralysis caused by anterior 
poliomyelitis of a mild type is not discovered until the child begins 
to walk, when the awkward gait or limp, or the distortion of a 
foot, may make it evident. 

In a few hours or a few days after the first symptoms of the 
disease the paralysis appears; its area may extend slowly after 



DISEASES OF THE NERVOUS SYSTEM 601 

it is recognized, or its extreme limit may be reached at once. 
This original paralysis is always greater than that which finally 
persists. The duration of the first stage may be from a few 
hours to a week. 

2. Then follows a stationary period, lasting from a week to a 
month; the constitutional symptoms cease but the paralysis 
remains. 

3. This is succeeded by the stage of partial recovery, lasting 
from one to six months or longer. The muscles which were 
paralyzed because of the secondary congestion and exudation 
about the local myelitis recover their power in whole or in part, 
while those muscles supplied from the area in the cord in which 
the nerve cells have been destroyed waste away. At this time 
the contractions and distortions in the paralyzed limbs appear. 

4. The chronic stage. This may be considered to last until 
adult age or until the ultimate effect on the individual, due to 
the retardation of the growth and unbalancing of the mechanical 
equilibrium of the body may be complete. 

The sensation of the paralyzed part is not affected except in 
the extreme cases. The temperature is lower from the first. In 
many instances the limb is not only cold, but it is congested and 
blue. These circulatory disturbances are caused primarily by 
the interference with the vasomotor system, but they are con- 
firmed later by the atrophy of the muscles and by the permanent 
contraction of the bloodvessels. Thus, in general, the impair- 
ment of the circulation corresponds to the degree of the paralysis, 
but not absolutely so. In certain cases the paralysis may be 
limited in extent, and yet the limb may be cold and congested, 
while in others in which the loss of power is much greater the 
temperature is but slightly lowered and the color remains normal. 
The same is true of retardation of growth. In most instances 
the ultimate shortening of the limb corresponds to the degree of 
the paralysis and consequent loss of function; but occasionally 
cases are seen in which the growth is markedly retarded, although 
but few of the muscles are paralyzed. 

Diagnosis. — It is doubtful if the diagnosis of acute anterior 
poliomyelitis could be made before the stage of paralysis. But 
after the paralysis has appeared there should be little difficulty 
in interpreting the symptoms. It is a disease usually of acute 
onset, followed by paralysis of certain muscular groups or of 
entire members. It is a flaccid paralysis, the reflexes are lost, 
the muscles no longer contract under faradism, and the reaction 



602 ORTHOPEDIC S URGER Y 

of degeneration soon appears; the tissues waste, and the circula- 
tion is impaired in the affected parts. 

It is usual to consider first in differential diagnosis the paralyses 
of cerebral origin, but this is more for the purpose of calling 
attention to the essential differences between the two than because 
they are likely to be confounded by one acquainted with the 
ordinary characteristics of cerebral and spinal disease. 

Paralysis of Cerebral Origin in Childhood. — The common form is 
hemiplegia. It usually follows convulsions, and the intelligence 
may be impaired. The paralysis is not complete, nor is it limited 
to groups of muscles; it is rather powerlessness or impairment of 
function, due to loss of cerebral control. The reflexes are in- 
creased and limbs are stiffened, not flaccid. The electrical reac- 
tions are not lost or changed in quality. Paralysis of cerebral 
origin may be also paraplegic or diplegic in its distribution, but 
in these cases the general characteristics are the same as in the 
hemiplegic form, except that the intelligence is more markedly 
affected. 

Other Forms of Spinal Paralysis. — Transverse myelitis is very 
uncommon in childhood. In this disease the distribution is 
equal, the reflexes are at first increased, and sensation as well as 
motion is lost. 

Pott's Paraplegia. — In this form of paralysis, also, the distribu- 
tion is equal, the reflexes are increased, and the signs of the dis- 
ease of the spine are always present. 

Spastic Spinal Paraplegia. — In this as in the preceding form 
the distribution is equal, and the reflexes are exaggerated. 

Rheumatism and Joint Disease. — In orthopedic practice anterior 
poliomyelitis is not often seen in the stage of onset unless pain 
is a prominent symptom, when the disease may be mistaken for 
rheumatism or for some form of joint disease. Cases of this 
type are not uncommon. The muscles are sensitive to pressure 
and the movements of the joints cause discomfort. In certain 
instances the paralysis may not be apparent on the first examina- 
tion; when it does appear the diagnosis is, of course, established; 
therefore, the characteristics of diseases of the joints need not be 
detailed. 

Multiple Neuritis. — Multiple neuritis is usually a sequel of in- 
fectious diseases, or of metallic poisoning. In the cases due to 
metallic poisoning with lead or arsenic the paralysis usually begins 
in the extensors of the hands and feet, and is symmetrical in its 
distribution. This is true, also, of the localized forms of paralysis 



DISEASES OF THE NEB VOUS SYSTEM 603 

following contagious diseases in which the dorsal flexors of the 
feet are most often involved. In multiple neuritis there is usually 
local sensitiveness lasting a longer time than in poliomyelitis; 
the paralysis is gradual in its onset, and sensation as well as 
motion is affected. 

Diphtheritic Paralysis. — Diphtheria is the most common cause 
of general weakness terminating in paralysis, but in these cases 
there is usually a history of the preceding disease. The paralysis 
appears first in the muscles of the throat and neck, and a general 
and increasing weakness precedes for a considerable interval the 
complete loss of power. 

Weakness. Pseudoparalysis. — Weakness caused by rhachitis or 
so-called pseudoparalysis, due to this or to other affections, is 
readily distinguished from actual paralysis by pricking the part 
with a pin, when muscular contraction and movement of the limb 
will be evident. This test of function is of value in showing 
the distribution of actual paralysis. Loss of power in the tibialis 
anticus muscle, for example, causes valgus resembling closely the 
ordinary valgus due to simple weakness. In simple weakness 
the child withdraws the foot from the point of the pin, and the 
ability to move it in all directions is very evident ; but if the tibialis 
anticus muscle is paralyzed the foot is always flexed in the ab- 
ducted attitude. The same test may be made for paralysis of 
other muscles or muscular groups. It is a test that is easily 
applied and that is especially useful in the examination of young 
children. 

Obstetrical Paralysis. — Paralysis of the arm due to anterior 
poliomyelitis is infrequent as compared with that of the lower 
extremity. This form might be mistaken for obstetrical par- 
alysis, but the history of the disability and its distribution should 
make the diagnosis clear. 

Prognosis. — Only in very rare instances does the disease of 
itself cause death. The prognosis as to function depends pri- 
marily upon the area of the destructive disease of the cord, 
secondarily upon the treatment of the weakened or disabled part. 
As has been stated, the extent of the primary paralysis is very 
much greater than that which ultimately remains when the inflam- 
matory changes about the diseased area in the cord have subsided. 

The Electrical Test. — During the early stages of the disease the 
degree of final paralysis may be fairly estimated by the electrical 
reaction. Within a week after the initial paralysis the reaction 
to the faradic current in the muscles and nerves in direct con- 



604 ORTHOPEDIC S UBGEB Y 

nection with the diseased area is lessened and is soon lost. If 
the faradic irritability is retained in the paralyzed muscles, or if 
it is merely diminished, recovery may be predicted. The muscles 
which no longer react to the faradic irritation may still be made 
to contract by the galvanic current. In normal muscles the 
reaction is greatest at the closing of the negative pole. In the 
paralyzed muscles the reaction is slower, it requires stronger stimu- 
lation, and the contraction is greater at the closing of the positive 
pole. This is known as the reaction of degeneration. The loss 




Anterior poliomyelitis. Extreme flexion deformity at the hips, inducing quadrupedal 
locomotion. (Gibney.) 

of faradic reaction and the change in the galvanic reaction indicate 
that the function of the affected muscle is lost, although certain of 
its fibres may in time regain their power. 

The Effects of Paralysis of Different Muscles and Groups of Muscles 
upon Function. — The principal interest in anterior poliomyelitis 
lies in its immediate and ultimate effects upon the functional 
ability of the individual. These effects may be classified as 
deformity of the part directly involved and the influence of weak- 
ness, deformity, and loss of growth upon the body as a whole. 

Causes of Deformity. — The deformities of anterior poliomyelitis 
are caused: 



DISEASES OF THE NERVOUS SYSTEM 605 

1. By force of gravity. 

2. By the unopposed action of the muscles whose power remains. 

3. By functional use. 

All these and other less important causes of deformity are, of 
course, combined in most instances. The relative importance of 
each factor varies, according to the muscular group that is involved, 
with the age of the patient, and with the strain to which the part 
is subjected. The influence of the different factors can be studied 
best in the foot. 

Muscular Action and Gravity. — In by far the larger number of 
cases, one or more of the dorsal flexors of the foot are involved. 
This is illustrated by the statistics of acquired talipes, tabulated 
elsewhere, the equinus type of deformity being three times as 
common as the calcaneus form. 

If the anterior muscles are paralyzed before the walking age, 
the foot drops under the influence of the force of gravity into 
the attitude of equinus. If this attitude is allowed to persist, the 
muscles on the posterior aspect of the limb, accommodating 
themselves to the habitual attitude become structurally shortened. 
In such cases the equinus deformity is caused by the force of 
gravity; it is increased by muscular action and it is fixed by 
muscular adaptation. That deformity is not caused directly by 
muscular action is shown by the fact that it may be prevented by 
stimulating the paralyzed muscles from time to time with galvanism, 
or even by systematic passive movements to the limit of dorsal 
flexion. Deformity is thus prevented, not by opposing muscular 
action, but by stretching the active muscles to the full limit and 
thus preventing muscular adaptation and structural change. In 
the instance cited gravity and muscular activity are combined 
in the production of equinus, but in other instances gravity and 
muscular power may be opposed to one another. If, for example, 
the calf muscle is paralyzed while the anterior group retains its 
power, the deformity of calcaneus does not appear until the child 
begins to use the foot, when the peculiar helplessness calls atten- 
tion to the disability, if the diagnosis has not been made before. 
Thus it is that equinus may be present when the child is still 
in arms, while the opposite deformity develops much more slowly. 

Habitual Posture. — There are other cases in which every ves- 
tige of muscular power is lost and in which the foot dangles. 
In this class there is no functional activity or tonic contraction of 
the muscles; consequently deformity is slow in making its appear- 
ance; it is not often extreme, and it becomes fixed only by the 



606 



OR TH OPE DIC SURGERY 



structural shortening of inactive tissues, the ligaments, fasciae, 
and the atrophied muscles. There are, of course, other causes 
for habitual posture than the force of gravity and muscular action, 
such as, for example, the position of convenience in which a weak 
or disabled part might be placed, but such causes of deformity 

may be considered as instances 
fig. 390 of functional use or rather of 

adaptation to local weakness. 

Functional Use as a Cause of 
Deformity. — Thus far the force 
of gravity, unbalanced muscular 
power, and the structural changes 
in the tissues have been consid- 
ered in the etiology of deformity 
as it might develop in infancy 
When, however, the patient 
stands and walks, existing de- 
formities are exaggerated and 
confirmed by the weight of the 
body falling on the unbalanced 
part, and by the action of the 
muscles in the attempt to supply 
the function of those that are 
paralyzed. Thus it is that the 
deformity develops far more 
rapidly when a fair amount of 
muscular power remains than 
when it is completely lost. (See 
Talipes.) 

Subluxation. — Aside from the 
distortions due to the causes that 
have been mentioned, there are 
others induced simply by weak- 
ness; for example, laxity of liga- 
ments and the failure of mus- 

Anterior poliomyelitis. Duration seven , ■, j« 

years. Showing atrophy and slight lateral Clllar Support may permit dlS- 

curvature of the spine; two and a quarter tort i on Q f a Hmb and SublllX- 

mches of shortening. 

ation or even displacement at a 
joint (Figs. 391 and 392). Complete displacement is uncommon, 
and occurs practically only at the hip. In such cases there is 
usually flexion deformity of the limb, the femur being suspended 
by the contracted tissues attached to the anterior superior spine. 




DISEA SES OF THE NER VO US S YS TEM 607 

This unyielding band forms a fulcrum by means of which force 
applied at the knee may cause sudden displacement of the head 
of the femur inward or upward and backward. 

Deformities of the Upper Extremity. — Deformities caused by 
paralysis of the muscles of the shoulder are usually slight 
because the part is not subjected to the strain of weight bear- 
ing, and because the force of gravity is opposed to muscular con- 
traction. In these cases the loss of support and the tension 
on the capsule allow a considerable separation of the joint sur- 
faces so that the atrophied head of the humerus may be displaced 
forward or backward; but there is not often fixed displacement, 
and consequently persistent distortion due to this cause is un- 
usual. 

Paralysis of the muscles of the forearm and of the hand is fol- 
lowed after a time by deformity of the fingers, caused primarily 
by unopposed muscular action, secondarily by accommodation 
and atrophy. 

Deformities of the Neck. — Paralysis of one or more of the 
muscles of the neck may induce a paralytic torticollis. This 
is, however, uncommon. 

Deformities of the Trunk. — Paralysis of the muscles of the trunk 
may induce distortion and extreme lateral curvature of the spine. 
This curvature is not usually caused, as might at first appear, 
by contraction of the active muscles and thus a bending of the 
trunk with a convexity toward the weaker side. As a rule, the 
curvature is, as a whole, in the opposite direction. This is ex- 
plained by the fact that if the paralysis is limited to one side 
and is extensive enough to cause distortion of the trunk, the 
muscles of respiration being involved, the chest wall becomes 
inactive and collapses. In compensation the opposite side of 
the thorax increases in volume and lung capacity and the weak, 
atrophied, and sunken side is drawn toward it. The same effect 
is observed when the arm and the shoulder muscles are paralyzed, 
the spine bending toward the side that is still active. 

Paralysis of the posterior group of muscles, if extreme, may 
induce kyphosis. Paralysis of the muscles of the abdomen may 
cause lordosis, but in this group of cases the lower extremities 
are usually involved, and the secondary distortions due to posture 
and to functional use mask the direct effect of the paralysis of 
the muscles of the trunk. And, again, the overuse of the arm 
muscles in patients whose lower extremities are paralyzed, and 
the suspension of the body on crutches in walking, modify the 



608 



ORTHOPEDIC SURGERY 



ultimate effects in those cases in which the paralysis is wide- 
spread in its area. (See Lateral Curvature.) 

Retardation of Growth and Secondary Deformities. — The effects 
of anterior poliomyelitis are not limited to the paralysis and to 
atrophy of the muscles, but all the component tissues of the 
affected limb are involved as well. The bones become relatively 




Anterioripoliomyelitis, causing genu recurvatuni. (See Fig. 392.) . 

atrophied, and their growth is retarded to a degree fairly propor- 
tionate to the extent of the paralysis and to the functional dis- 
ability that has resulted. As has been stated, retardation of growth 
does not always correspond to the amount of paralysis. In some 
instances paralysis of a single muscle, which does not seriously 
compromise the function of the part, is accompanied by greater 



DISEASES OF THE NERVOUS SYSTEM 609 

shortening of the limb than in other cases in which the paralysis 
is far more extensive. Thus it may be inferred that certain 
cells in the spinal cord are especially concerned in the growth 
and nutrition of the bones, and that interference with the function 
of these cells may not correspond absolutely to the extent of the 
destructive process. However this may be, it is certain that 
atrophy and retardation of growth are much greater when a 
limb is not used than when by the aid of apparatus it has been 
enabled to carry out, in part at least, its proper function. It is 
evident, also, that retardation of growth will be more marked 
during the period of rapid development; thus, the younger the 
patient the greater should be the ultimate inequality of the limbs. 
Retakdation of Growth. — The ultimate shortening varies 
from one to three inches. In the slighter degrees of paralysis 







Anterior poliomyelitis. Paralysis of muscles at the hip allows subluxation of the femur. 
The same patient as in Fig. 391. 

affecting the leg the shortening may be less than an inch, but 
when the thigh muscles are paralyzed also it may be much more 
(Fig. 390). This inequality is usually very evident in the size 
of the two feet. 

When both limbs are paralyzed, so that locomotion is very 
seriously interfered with, the retardation of growth is especially 
marked, and the contrast between the trunk of the patient and 
the attenuated lower extremities is very striking. 

Secondary Deformities must include, besides those already 
mentioned, the compensatory distortions of the trunk that may 
follow paralysis of the limbs. Thus a short leg might cause a 
lateral curvature of the spine, or great flexion contraction of the 
thigh might induce abnormal lordosis. As a matter of fact, the 
final effects of disabilities of this character are very complex, and 

39 



610 ORTHOPEDIC SURGERY 

are influenced by many factors of which only a general indication 
is practicable. 

Treatment. — The treatment of the acute stage of anterior 
poliomyelitis is symptomatic. If the diagnosis has been made, 
such measures as would tend to relieve the congestion about the dis- 
eased area should be employed ; cathartics, sedatives, and counter- 
irritation of the spine, for example. When the acute symp- 
toms have subsided local treatment to maintain as far as possible 
the nutrition of the muscles, to prevent deformity and to relieve 
the strain upon the weakened tissues, is indicated. The nutrition 
of the parts may be improved by massage, by muscle-beating, 
by the direct application of heat to the cold extremities, and by 
the use of galvanism, as long as it will induce contraction of the 
paralyzed muscles. 

Deformity may be prevented by moving each joint to the limit 
of the range of motion in all directions several times a day, and 
by supporting the limb with appropriate apparatus. Deformity 
in those parts in which it is favored by muscular action and by 
the force of gravity appears much more rapidly than is generally 
supposed. The indications of equinus, for example, are apparent 
within a few weeks after paralysis of the anterior muscles of the 
leg. The first indication of such deformity in this class is the 
discomfort caused by passively moving the foot toward dorsal 
flexion. This limitation of the range of motion rapidly increases, 
and as it increases it is confirmed by muscular adaptation and 
finally by structural shortening. 

The Principles of Mechanical Treatment. — The object of a brace 
is to prevent the deformity due to weakness and to utilize the 
muscular power that remains, so that the disabled member may 
carry out its function. As each muscle has an essential function 
the paralysis of any one must be followed by a certain disability 
and usually by deformity. Muscles vary in importance as they do 
in strength, and the ultimate disability caused by paralysis may be 
predicted very accurately by one who is familiar with this function. 

Paralysis of the Anterior Muscles of the Leg. — Par- 
alysis of the anterior leg group causes the so-called steppage gait; 
the toes drag on the floor when the limb is swung forward, and 
this necessitates an awkward lifting of the knee. The result of 
such paralysis is equinus. Slight equinus has a tendency to 
throw the knee backward, "recurvatum," in order that the 
patient may place the entire sole on the ground. More marked 
equinus obliges the patient to bear the weight entirely on the 



DISEASES OF THE NERVOUS SYSTEM 



611 



front of the foot, and causes flexion both at the knee and hip. 
If but one of the muscles of the anterior group is paralyzed the 
tendency to equinus is in so far lessened, but there is an inclina- 
tion to lateral distortion. Paralysis of the anterior muscles causes 
an awkward gait and often deformity, but the propelling force of 
the limb remains. The indication for support is simple, to pre- 
vent the foot from dropping to the extent that incommodes the 
patient, or practically to hold the foot at a right angle with the 
leg. 

Paralysis of the Posterior Muscles of the Leg. — If, 
on the other hand, the calf muscle is paralyzed the resistance of 




6 



*^m 



The Judson brace for paralysis of the quadriceps extensor muscle in connection 
with deformity of the foot. 



the foot is lost and it is simply dorsiflexed when weight is thrown 
upon it. Thus the brace must be arranged to prevent dorsal 
flexion, and it must be strong enough to support the strain which 
is transmitted from the foot-plate of the brace to the front of 
the leg. The various weaknesses and deformities of the foot and 
the means of treating them are described at length elsewhere. 
(See Talipes.) 

Paralysis of the calf muscle not only affects the foot, but it 
weakens the knee as well, and genu recurvatum is often a second- 



612 



ORTHOPEDIC SURGERY 



ary effect. In many instances, therefore, it will be necessary 
to support the knee as well as the ankle during the earlier 
stages of the treatment. 




A brace for complete paralysis of the 
limb, showing a form of lock at the 
knee and a limited joint at the ankle. 



Anterior poliomyelitis. Paralysis of the 
anterior and posterior muscles. Recur- 
vation of the right knee. 



Paralysis of the Thigh Muscles. — Paralysis of the quad- 
riceps extensor muscle causes primarily a peculiar gait. The 
patient, unable to extend the leg upon the thigh, throws or swings 
it forward, then locks the joint by direct contact of the^bones 
and by the resistance of the posterior tissues, by inclining the 



DTSEASES OF THE NERVOUS SYSTEM 613 

body somewhat forward as the weight falls upon it. In this 
manner, again, the knee may be overextended. Or if extension 
is checked by shortening of the tissues, induced, for example, 
by habitual assumption of the sitting posture, the patient being 
unable to lock the joint effectively by complete contact of the 
bones, often trips and falls because of the insecurity of the sup- 
port. When in the normal subject the weight is borne upon one 
limb in the attitude of rest, in which the muscles are thrown out 
of action, the knee-joint is locked, but the insecurity of this sup- 
port is illustrated by the school-boy's trick of striking the back 
of the knee with the hand, when, the muscles being taken una- 
wares, the person falls to the ground. This insecurity is constant 
when the extensor of the leg is paralyzed. 

Paralysis limited to the quadriceps extensor muscle is, how- 
ever, very unusual. In almost all cases some of the leg muscles 
are involved also, and the brace usually must serve to support 
the foot as well as the knee. In its ordinary form such a brace 
is constructed of two lateral upright bars, reaching nearly to the 
pubes on the inner and to the trochanter on the outer side, joined 
to one another by bands passing beneath the thigh and the calf, 
and attached to a light steel foot-plate. If the dorsal flexors of 
the foot are paralyzed the ankle-joint is arranged to allow dorsal 
flexion, but to prevent extension beyond the right angle. If the 
calf muscle is paralyzed a reverse catch is used, or the uprights 
are attached directly to the foot-plate without a joint (Fig. 394); 
or the so-called limited joint, allowing only a few degrees of motion 
in either direction, is used (Fig. 395). (See Talipes.) In the 
treatment of young children the joint is also omitted at the knee, 
the limb being firmly held in the extended position during the 
active period (Figs. 394 and 397). This is of advantage because 
the joint is the weakest part of the brace and it soon becomes 
loose under the severe strain to which it is subjected. In older sub- 
jects a joint is arranged with a spring catch, the brace being held 
in the straight position when the patient is walking about, but 
allowing flexion when the sitting posture is assumed. This is, 
of course, a great convenience (Fig. 395). In fitting the brace 
the lateral bars should be adjusted to support the limb without 
uncomfortable pressure, and the joints should be exactly opposite 
the normal centres of motion. The thigh and leg bands should 
be properly fitted to the contour of the soft parts so that half 
the limb is contained within them. These are smoothly covered 
with leather, and the limb is held in position by leather bands 



614 



ORTHOPEDIC SURGERY 



that complete the circumference. Other bands are applied across 
the front or back of the limb, either to support it or to fix it firmly 
in place. In the ordinary brace without the joint at the knee 
there are three anterior bands, one across the front of the thigh, 
another across the leg, and the third, a wide knee-cap, supports 
the greater part of the strain (Fig. 397). 

Paralysis of the Muscles of the Hip. — The effect of par- 
alysis of the muscles about the hip is difficult to describe, as in 




Brace for complete paralysis of the anterior muscles of the limb; before and after covering. 



these cases many other muscles are usually involved. If all 
the muscles are paralyzed the thigh dangles. This is, however, 
very unusual, for the tensor vaginae femoris almost always retains 
its power and it is one of the causes of flexion deformity which is 
so often present in cases of this character. 

Paralysis of the iliopsoas muscle makes it impossible for the 
patient to flex the thigh directly. If the adductors are paralyzed 
he must lift the thigh with the hand when adduction is desired. 



DISEASES OF THE NERVOUS SYSTEM 



611 



Paralysis of the glutei is made evident by the atrophy and by the 
weakness of the extending power of the limb. 

The distribution of the paralysis of the muscles of the hip may 
be ascertained by placing the patient in the recumbent posture; 
the leg is then lifted from 
the table, and by placing 
the thigh in different posi- 
tions the ability of the 
patient to move it may be 
tested, in older subjects 
by voluntary effort, in 
younger ones by pricking 
the part slightly with a pin. 

General weakness of the 
muscles of the hip causes 
an awkward, insecure gait, 
accompanied usually by 
outward rotation of the 
limb, and, as has been 
stated, there is almost al- 
ways accompanying par- 
alysis of other muscles 
of the extremity. In such 
cases a pelvic band must 
be attached to the leg 
brace. The pelvic band 
is made of sheet steel of 
about 18 gauge, two inches 
wide, fitted to the pelvis, 
which it encircles midway 
between the crest of the 
ilium and the trochanter. 
At this point it is attached 
to the brace by a free joint 
(Fig. 398). When the band 
is accurately adjusted and 
strapped firmly about the pelvis, the necessary security is assured 
and the attitude of the limb in walking can be regulated. If 
greater support is desired a perineal band may be applied as 
described in the chapter on Disease of the Hip-joint. 

If both limbs are paralyzed double braces must be used. If 
the muscles of the lower part of the back are much weakened 




Leg brace, with pelvic band. Double uprights. 
No joint at knee. For paralysis of the anterior 
thigh and leg muscles. 



616 ORTHOPEDIC SURGERY 

the pelvic band may be replaced by a corset or some form of back 
brace. Fortunately these cases are uncommon. 

Paralytic Scoliosis.- — Paralytic scoliosis requires the support 
of corsets or braces as a rule, such as are used in the treatment 
of other forms of distortion of the back. (See Lateral Curvature.) 

Paralysis of the Arm. — Paralysis of the arm is comparatively 
uncommon, and treatment is rarely demanded. 

In some instances a shoulder support may be of service or a 
brace to hold the arm at a right angle if the biceps is paralyzed. 
If the muscles of the scapula retain their power the operation of 
arthrodesis might be of service in fixing the dangling joint, and 
the same operation might be useful at the elbow. It is, of course, 
evident that one of the lower extremities, although hopelessly 
weakened, may be braced so that it may serve as a simple prop 
to bear weight, but as the function of the arm is quite different, 
extensive paralysis of its muscles makes it practically useless to 
the individual. 

Operative Treatment. The Reduction of Deformity. — In a 
large proportion of the cases of anterior poliomyelitis the patients 
are not seen by the orthopedic surgeon until months or years 
have elapsed since the original attack. They are then brought 
for treatment because of secondary deformity often of an extreme 
degree. At least half of the cases of talipes are due to this 
cause, and with the deformity of the foot are often combined other 
distortions varying in degree with the extent of the paralysis. 
Many of the patients hobble about on a distorted foot, others 
use crutches, and in a smaller number the only method of loco- 
motion is creeping on all -fours. In the cases in which the patient 
has habitually used crutches allowing the paralyzed limb to 
"dangle," there is usually marked flexion at the three joints. 
The thigh is flexed upon the pelvis, the leg is flexed upon the 
thigh, and the foot hangs downward and inward (plantar flexed) 
in an attitude of equino varus. 

However extreme the paralysis of a lower extremity may be, 
the limb may be made useful as a prop when properly braced; 
this prop will enable the patient to dispense with the use of crutches 
and thus free the arms from unnecessary work. Even if both 
limbs are paralyzed they may at least serve as supports to enable 
the patient to stand erect and to propel himself with the aid of 
crutches. If a limb has been disused for a long time, the atrophy 
is usually extreme, the bones are fragile, and the growth has been 
greatly retarded as compared with those limbs in which deformity 



DISEASES OF THE NEB VOUS SYSTEM 617 

has been prevented and in which the weight of the body has been 
sustained in functional use. In this class of cases the first step 
must be the reduction of deformity; the foot must be brought 
to a right angle with the leg, the limb must be brought to the 
straight line, and the flexion at the hip must be overcome in order 
to enable the patient to stand erect without bending the spine 
forward in compensatory lordosis. 

Acquired deformity of the foot is far less resistant than is the 
congenital form, and by tenotomy and the proper application of 
force it may be readily straightened, usually at one sitting. 

The flexion contraction at the knee may be overcome also by 
careful and persistent manual stretching combined, if necessary, 
with division of the contracted tissues on the posterior aspect of 
the joint. (See page 418.) 

The flexion deformity at the hip is usually fixed by the con- 
traction of the tissues about the anterior superior spine of the 
ilium, including the tensor vaginae femoris muscle, which is rarely 
paralyzed. These tissues, together with the fascia, may be divided 
subcutaneously, or by open incision if necessary; after which 
the deformity may be reduced by gradual forcible extension of the 
thigh while the pelvis is fixed by flexing the other limb upon the 
body. When the contraction deformities are overcome lateral 
deviation at the knee is corrected, if it be present, in the same 
manner, and the bony points having been carefully protected by 
padding a long spica plaster bandage is applied to fix the limb. 

The lesser degrees of deformity may be reduced by other 
means, for example, by repeated applications of plaster bandages 
under slight corrective force, or by manipulation, or by braces 
and bandaging. 

Paralytic knock-knee may be corrected by the Thomas knock- 
knee brace, and this brace when attached to a pelvic band is a 
useful form of support in the routine treatment of paralysis of 
the leg (Fig. 378). 

The Thomas caliper knee brace is another cheap and useful 
support. It is of special service when there is flexion or lateral 
deformity of the limb (Fig. 282). 

When distortion has been overcome and when functional use 
has been made possible by proper support, the development of 
active muscles which have been thrown out of use by the distor- 
tions, and of those in which part of the muscular substance has 
been retained, is surprising. In many of these cases the- distor- 
tions which developed during the temporary paralysis have alone 



618 



ORTHOPEDIC SURGERY 



prevented recovery, and this latent power may be revived even 
after years of disuse. Thus in many instances prognosis is 
impossible until the deformities have been corrected and until 
the limb, properly supported, has been enabled to resume its 
function. 

Tendon Transplantation. — This operation is best adapted 
to the treatment of distortions of the foot caused by paralysis of 
the muscles of the leg, and the procedure is described at length 
in that section. 




Paralysis of the left deltoid muscle, showing the elevation of the shoulder when the 
patient attempts to abduct the arm. (See Fig. 400.) 

Hoffa's Operation for Paralysis of the Deltoid Muscle. 
— One of the most useful operations of this class is the transplanta- 
tion of the trapezius muscle for paralysis of the deltoid. In cases 
cf this class there is disabling laxity or even subluxation at 
the articulation, and the exaggerated elevation of the shoulder 
when the patient attempts to raise the arm makes the disability 
very noticeable (Fig. 399). 

A broad flap of skin, its convexity over the upper quarter of 
the deltoid muscle, is raised exposing the trapezius. This is 



DISEASES OF THE NERVOUS SYSTEM 



619 



thoroughly separated from its attachment to the spine of the 
scapular and to the clavicle. The arm is then abducted and the 
flap of muscle, made tense, is sewed with numerous silk sutures 
to the atrophied deltoid and underlying capsule of the joint. The 
skin wound is then closed and the limb is fixed in complete 
abduction by means of a plaster bandage. This attitude should be 
retained for about two months. Afte ward massage and exercises 
should be employed. The humerus is usually held securely, a 




Illustrating the improvement in the range of abduction obtained by transplantation 
of the trapezius muscle. The line of the incision is shown. 

certain power of abduction is restored, and the functional ability 
often greatly increased (Figs. 399 and 400). 

Transplantation of the Sartoritjs Muscle. — In cases in 
which the quadriceps extensor muscle is paralyzed its function 
may be in part restored by transplantation of the Sartorius, 
as suggested by Goldthwait. A slightly curved incision is made 
from the patella inward and upward to the middle third of the 



620 ORTHOPEDIC S URGES Y 

thigh. The Sartorius is exposed, divided near its insertion and 
thoroughly separated from the surrounding parts. Its extremity 
is then inserted into an opening made in the tendinous expansion 
of the quadriceps muscle, to which and to the patella it is firmly 
attached. The extended position should be retained for several 
months. In favorable cases a useful degree of power of extension 
is supplied. 

Paralysis of the muscles of the arm and hand is comparatively 
unusual. The operation of tendon shortening combined with 
transplantation of the tendons of one or more active muscles 
may be of service in the treatment of wrist-drop, and opportunities 
may suggest themselves in other situations whenever it is possible 
to utilize the muscular power to better advantage. 

Arthrodesis. — As has been stated of tendon transplantation, 
arthrodesis is of greatest service at the ankle-joint, where it may 
serve to fix the foot at a right angle with the leg. (See Talipes.) 
In exceptional cases arthrodesis or excision at the knee may be 
advisable in the older patients, but in young subjects the strain 
upon the long, weak lever formed by the two bones will almost 
always induce deformity. Arthrodesis at the hip might be of 
service in cases of complete paralysis of the pelvic muscles. The 
operation is performed as for arthrotomy in the treatment of con- 
genital displacement of the hip (see page 544), except that the 
cartilage is thoroughly removed from the head of the femur and 
from the acetabulum. A short spica plaster support should be 
worn until union is firm. 

Arthrodesis at the shoulder may be of service when the supporting 
muscles are paralyzed. The method of opening the joint is des- 
cribed on page 489. 

Arthrodesis at the elbow and wrist may be of service in assuring 
an improved attitude. Whenever possible the operation should 
be reinforced by tendon or muscle transplantation. 

Osteotomy. — In rare instances, particularly in the extreme 
deformities in the adult, osteotomy of the femur at the hip 
or knee may be necessary in order to overcome resistant dis- 
tortion. 

Nerve Grafting. — A number of operations have been per- 
formed recently with the aim of restoring muscular power in 
paralyzed muscles by uniting the inactive nerve with one which is 
still in communication with the nerve centres. Some encouraging 
results have been reported, but they are far from convincing. 
It hardly seems likely that a nerve that has been inactive for 



DISEASES OF THE NERVOUS SYSTEM 621 

years would retain a sufficiently normal structure to take up its 
function again even if the union with another nerve trunk were 
perfect. 1 

Recapitulation of Treatment. — This consists in support and 
electrical stimulation of the muscles during the period of recovery, 
together with a suitable brace to hold the limb in the best possible 
position for usefulness when the final extent of the paralysis has 
become evident. With the support any treatment that will im- 
prove the nutrition of the part is of service; massage and muscle- 
beating are of special value. The limb in which the circulation 
is deficient should be protected from the cold by proper covering, 
and its nutrition may be improved by the direct application of 
heat, the hot-air or hot-water bath both being useful. Above all 
else, functional use, which is made possible by apparatus, is of the 
first importance in preserving and stimulating whatever muscular 
power remains; and special gymnastic exercises to this end may 
be employed if practicable. The prevention of deformity during 
the growing period is of great importance. Every morning and 
night the joints of the paralyzed part should be passively moved 
to the normal limits in all directions in order to prevent the gradual 
limitation of the range of motion which is the first indication of 
the deformity. Lateral deviation of the limb or foot may be 
prevented by passive manipulation and by careful adjustment 
or modification of the support. Braces should be strong and as 
simple as may be in construction. Elastic bands and springs, 
applied with the design of replacing paralyzed muscles, are of 
little practical use, since they are ineffective in action, difficult 
to adjust, and easily disarranged. The parent, when treatment 
is begun, must be impressed with the fact that a brace must be 
strong enough to serve its purpose even though its weight be 
objectionable; that its period of usefulness is limited, and that it 
must be replaced when it is outgrown ; that the breaking of a brace 
from time to time is unavoidable, and that such accidents, in so 
far as they are evidences of the functional activity of the patient, 
are favorable indications. 

Careful supervision of the patient, even though the weakness 
is not great, will be necessary during the period of growth. The 
contrast between the development and symmetry, the muscular 
power and practical utility of a limb that has received this care 
and supervision, and one that has be:n neglected, is sufficiently 

1 Spitzy, Amer. Jour. Orth. Surgery, August, 1904, 



622 ORTHOPEDIC SURGERY 

striking to impress anyone with the necessity for this tedious 
and apparently never-ending treatment. 

Thus, in this as in other chronic diseases and disabilities the 
character and the duration of the treatment, its object, and the 
final results that one may expect to attain by it, should be ex- 
plained to the parents when the care of the patient is undertaken. 



CHAPTER XVIII. 

DISEASES OF THE NERVOUS SYSTEM (Continued). 

Cerebral Paralysis of Childhood— Spastic Paralysis. 

Cerebral paralysis or palsy is in orthopedic practice secono 
only in frequency and importance to anterior poliomyelitis. It 
is, however, entirely different in its distribution and in its effects. 
It is a form of disability that is characterized by motor weakness, 
by stiffness and loss of control, rather than by paralysis. It 
affects entire members and it results in atrophy, contractions, and 
deformity. 

It may involve half the body, hemiplegia. 

It may be limited to the lower extremities, paraplegia. 

It may involve both the upper and lower extremities, diplegia. 

In rare instances but one extremity is affected, monoplegia. 

Distribution. — In 451 cases of cerebral paralysis analyzed by 
Peterson, 1 332 were of the hemiplegic type, 73 were of the 
diplegic type, and 46 were of the paraplegic type. In 121 cases 
observed at the Hospital for Ruptured and Crippled, 63 were 
paraplegic or diplegic and 58 were hemiplegic. The hemiplegic 
form of paralysis is usually acquired; the diplegic and paraplegic 
forms are usually congenital. 

Etiology and Pathology. — Cerebral paralysis may be divided 
into two classes — the congenital and the acquired. 

Congenital Paralysis. — Paralysis of intrauterine origin may be 
the result of maldevelopment or injury or a secondary effect of 
intercurrent disease of the mother. Paralysis caused by injury 
at birth is usually the result of rupture of bloodvessels of the 
meninges due to prolonged labor or to the pressure of instru- 
ments. 

Acquired Paralysis. — Acquired paralysis may be due to hemor- 
rhage, embolism, thrombosis, or to disease. Sachs 2 presents the 
following classification of causes and effects: 

1 American Text-book of Diseases of Children. 

2 Sachs, Nervous Diseases of Children. 



624 



OR THO PED W S UR OERY 



Paralysis of Intrauterine Origin. 

Large cerebral defects — true porencephaly. 

Hemorrhages of intrauterine origin — softening. 

Agenesis corticalis. 
Paralysis Occurring during Labor. 

Meningeal hemorrhage — very seldom intracerebral. Resulting 
conditions: meningoencephalitis chronica; sclerosis; cysts; atro- 
phies; porencephalies. 




Congenital cerebral diplegia (idiocy). 

Paralysis Acquired after Birth. 

1. Meningeal hemorrhage — very seldom intracerebral. Em- 
bolism: thrombosis in marantic conditions, and occasionally from 
syphilitic endoarteritis. Results of these vascular lesions: cysts; 
softening; atrophy; sclerosis, diffuse and lobar. 

2. Chronic meningitis. 

3. Hydrocephalus. 

4 r Primary encephalitis (Strumpell), 



DISEASES OF THE NERVOUS SYSTEM 



625 



General Symptoms. Motor. — The effect of the lesion of the 
brain and of the secondary changes in the cord is to impair the 
voluntary control of the limbs supplied from the affected area, 
and at the same time the inhibition of the higher centres is im- 
paired or lost. Thus, together with the loss of power, there is 
usually a corresponding exaggeration of the reflexes causing a 
spastic rigidity of the limbs. This induces distortion, which 
finally becomes fixed by the adaptive changes in the tissues. As 




Spastic paraplegia. 

the centres for the nutrition of the paralyzed parts are not 
involved, the muscles do not waste and the circulation is but little 
affected. Thus the atrophy as compared with paralysis of spinal 
origin (anterior poliomyelitis) is comparatively slight, and this, 
together with the retardation of growth, is due rather to the general 
effects of the disease and to the loss of function than to the direct 
influence of the nervous lesion. 

40 



626 ORTHOPEDIC SURGERY 

Mental. — In this form of paralysis the lesion is of the brain, 
and the direct injury of its structure and the interference with its 
development is likely to cause mental impairment. This mental 
impairment is usually more marked in the paraplegic or diplegic 
than in the hemiplegic form, because in the latter but half the 
brain is involved, and because the injury or disease occurs at a 
later period of its development. So, also, the mental development 
is usually less interfered with in the paraplegic than in the diplegic 
type. For, although both hemispheres were involved, yet the 
recovery of power in the arms shows that the injury was less exten- 
sive than when the weakness persists in one or both of the upper 
extremities. 

It is estimated that in 50 per cent, of the hemiplegic cases the 
patients are feeble-minded, although comparatively few (13 per 
cent.) are idiotic. In the paraplegic and diplegic forms of par- 
alysis about 70 per cent, of the patients are feeble-minded, and 
from 40 to 50 per cent, are idiotic. (Sachs.) 

Epilepsy is an accompaniment of about 45 per cent, of all 
forms of cerebral paralysis, and in 20 per cent, of the cases athetoid 
or associated movements in the paralyzed parts persist. (Peterson.) 

Congenital Weakness and Paralysis. 

The congenital form of cerebral paralysis is often seen in 
orthopedic clinics, because the effect of the lesion of the brain 
in retarding physical development first attracts the attention of 
the mother. Thus, infants are brought for examination because 
they are unable to sit or stand at the usual time. In certain 
instances the cause of the physical weakness is simple idiocy. In 
such cases the vacant expression, the inability of the child to recog- 
nize even its mother, the extreme weakness, and the absence of the 
spastic rigidity of the limbs will make the diagnosis clear. 

In another class of cases the weakness appears to be caused 
simply by retarded cerebral development. The patient is apathetic 
and weak, but there is no evidence of paralysis and the comparative 
intelligence of the patient distinguishes this type from the idiotic 
class. 

In the characteristic form of cerebral paralysis as seen in early 
life the child may be idiotic, or simply apathetic, or fairly 
normal in intelligence, but it is always weak, and in the sitting 
posture the spine is usually bent backward into a long, more or 
less rigid curve. It makes no effort to stand, and when placed 



DISEASES OF THE NERVOUS SYSTEM 627 

in the erect posture it will be noticed that the thighs are usually 
pressed closely against one another and that the feet are extended. 
The limbs are "stiff." There is a peculiar resistance to flexion 
at the extended joints, which slowly gives way under steady 
pressure. This is the characteristic spastic rigidity (Fig. 401). 

Deformities. — These children usually begin to stand and to 
walk at about the third year or later with an awkward, shuffling 
gait; the limbs are usually flexed, adducted, and rotated inward; 
the knees touch one another or the legs may be crossed, while 
the feet turn inward in a persistent attitude of slight equinovarus. 
The equilibrium is very easily disturbed, partly because of the 
deformities and partly because of direct lesion of the brain. In 
the majority of the congenital cases the paralysis is paraplegic in 
its distribution; perhaps 15 per cent, are of the hemiplegic variety, 
and in a somewhat larger number the paralysis is diplegic in 
distribution (Fig. 401). 

It has been stated that the typical deformity of the foot was 
equinovarus, but in older subjects who have walked about in the 
attitude of flexion at the hips and knees there may be an accom- 
modative distortion of the foot toward valgus, or even to an ex- 
treme degree of calcaneovalgus. 

As has been stated, in a certain number of cases the intelli- 
gence is not impaired, but more often the patients are distinctly 
feeble-minded. They are very nervous, easily startled, emotional, 
and are often unable to speak distinctly, yet it is interesting to 
note that this peculiar emotional excitability often passes for an 
extreme degree of brightness of intellect and quickness of per- 
ception. In fact, parents often remain unconvinced that the 
child is lacking in mental power until it reaches an age when 
comparison with other children makes this conclusion inevitable. 

Acquired Paralysis. 

As in adult life, the common form of acquired cerebral par- 
alysis in childhood is hemiplegia. About two-thirds of all the 
cases occur in the first three years of life; and in about 20 per 
cent, of these the affection of the brain is a complication of infec- 
tious disease. The onset is usually sudden, and is accompanied 
in the majority of cases by fever, convulsions, and loss of con- 
sciousness. When the child regains consciousness the paralysis 
of the arm and leg is at once evident, and in about 20 per cent, 
of the cases the face is paralyzed also. 



628 



OB THOPEDIC S UB GEB Y 



Deformities. — At first the paralysis is a simple powerlessress, 
but soon the exaggeration of the reflexes is evident. As has 
been stated, there is a loss of voluntary power and an increase of 
the reflexes or "stiffness" of the paralyzed members. They are 
no longer competent to assume the more difficult attitudes and 
functions, and these are replaced by those that are simpler; thus 
flexion becomes habitual. 

In typical hemiplegia the foot is plantar flexed and adducted. 
The leg is flexed on the thigh and the thigh on the trunk, and 
with the flexion adduction is usually 
FlG 403 combined. The arm is held against the 

thorax, the forearm is flexed upon the 
arm in an attitude midway between pro- 
nation and supination. The hand is 
flexed upon the arm and inclined toward 
the ulnar side and the fingers are clasped 
over the adducted thumb (Fig. 403). 

Disability. — The loss of power is not 
absolute; in most instances the patient 
is able to walk with an exaggerated limp, 
dragging the stiffened and distorted limb, 
which serves as a prop rather than as 
an active support. So, also, the control 
of the upper extremities is in part re- 
tained; the patient is able to abduct the 
arm, to partly extend the forearm, some- 
times to extend the fingers and to abduct 
the thumb, but the power to dorsiflex the 
hand and at the same time to extend 
the fingers is not usually retained in a 
case of this character. 

Loss of Growth.— The growth of the 
patient as a whole is usually retarded to 
a certain extent by the lesion of the brain. 
There is in addition a certain degree of 
inequality in the growth of the two halves 
of the body. This inequality is more 
marked in the upper than in the lower 
extremity. Shortening to the extent of 
an inch in the lower extremity is not 
usually exceeded, but the growth of the arm and hand may be very 
markedly checked. This disproportionate loss of growth in the 




Acquired cerebral hemiplegia. 



DISEASES OF THE NERVOUS SYSTEM 629 

upper over the lower extremity, although it may be explained in 
part by the situation of the lesion of the brain, depends more directly 
upon the interference with function. The lower extremity is rarely 
disabled to an extent that prevents its use in locomotion, conse- 
quently its nutrition is preserved; whereas, the same degree of 
paralysis of the arm utterly unfits it for its more difficult functions 
and it becomes a useless appendage. With the disuse of function 
there is a corresponding diminution of nutrition and a consequent 
atrophy and loss of growth. 

Extreme deformity and disability, as in the type described, are 
rather unusual. In many instances there is almost complete 
recovery from the paralysis, only an awkwardness and slowness 
of movement, combined with an increase of reflexes and a slight 
hemiatrophy of the body exists. In some cases a slight degree 
of equinus is the only deformity; in others weakness of the arm 
may persist, although complete control of the lower extremity 
has been regained. 

The final effect of the paralysis is almost always more marked 
in the upper than in the lower extremity; thus, when contrac- 
tions and deformities of the lower extremity are present the arm 
and hand are often practically disabled. 

Treatment. 1. Hemiplegia. — The treatment from the ortho- 
pedic standpoint consists in stimulating the nutrition of the 
paralyzed parts, in preventing deformity, and in improving the 
functional ability. The results of treatment are, of course, very 
greatly influenced by the mental condition of the patient. If 
the mental power is not impaired one may count upon the efforts 
of the patient for aid ; whereas, if the patient is idiotic there is but 
little encouragement for active treatment. If the patient is seen 
before the secondary contractions have appeared, deformity may 
be prevented in great degree by regular massage and by passive 
movements in the directions opposed to the habitual positions. If 
the spastic contraction is slight a light jointed leg brace attached 
to a pelvic band may be used. By this means the movements are 
controlled and the excessive expenditure of nervous energy neces- 
sary to guide the limb may be lessened. If the support is sup- 
plemented by massage and regular exercises the control of the 
limb may be greatly improved. 

In many instances the patients are not seen until late child- 
hood, when the deformities have become fixed. The foot is 
usually turned inward and downward (equinovarus) ; there is 
flexion at the knee and often flexion and adduction at the hip, 



630 OB THOPEDIC SURGERY 

the resistance of the contractions being dependent upon the dura- 
tion of the deformity. In such cases the distortions must be 
corrected by force and by division of more resistant tissues, in- 
cluding often the tendo Achillis, the plantar fascia, and in many 
instances the hamstrings and the adductors of the hip. The 
limb is then fixed in a plaster-of-Paris bandage for a sufficient 
time to overcome the more direct tendency to deformity. In 
correcting hemiplegic or paraplegic deformity one should be 
particular to overcome resistant contraction at the knee before 
dividing the tendo Achillis, for if the patient is allowed to walk 
afterward with a flexed knee the foot may assume the calcaneus 
deformity. As additional precaution the foot at the time of an 
operation should be fixed at a right angle with the limb ; not over- 
corrected as is usual. When the bandage is removed a brace is 
of service in guiding the limb, and regular massage and forcible 
passive movements together with proper exercises should be 
employed whenever practicable. In this class of cases the deformi- 
ties may be overcome in most instances, but there is a tendency 
toward flexion at the knee, and stiffness and awkwardness in 
movement usually persist. 

In many of the milder hemiplegic cases the only deformity is 
of the foot. This should be treated by division of the tendo 
Achillis and by support for a time until the deformity habit has 
disappeared. 

Tendon Transplantation. — If the arm is but slightly affected 
proper exercises will greatly improve its ability. In the more 
extreme cases, in which the fingers a e clasped over one another, 
treatment is of little avail. In another class, in which the patient 
has the power of extending the fingers only when the wrist is flexed, 
the power of dorsiflexion may be restored or improved by trans- 
planting the flexors of the carpus on the radial and ulnar border to 
the extensors, which have been overlapped and shortened to the 
prooper extent. These tendons may be exposed by lateral incisions, 
and may be attached to the dorsal tendons by passing them about 
the border of the radius and of the ulna, or the tendons may be 
elongated by silk, which may be inserted directly to the median sur- 
face of the tarsus or metatarsus. In such instances one hopes that 
fibrous tissue will be deposited about the artificial tendon and 
finally replace it. In other instances the two tendons have been 
pushed through an opening in the interosseous membrane to the 
dorsal surface of the wrist, and there united with the tendons of 
the extensors of the fingers. The results of these operations as 



DISEASES OF THE NERVOUS SYSTEM 



631 



far as improving the attitude is concerned are usually good. The 
transplantation of other tendons may be of service, but the opera- 
tion is limited in usefulness for the reasons stated. 1 Athetoid move- 
ments of the hand and arm may be relieved somewhat by prolonged 
fixation in a plaster bandage, or by arthrodesis at the wrist-joint. 




Cerebral paraplegia, second stage in treatment, the long replaced by the short spica. This 
patient, at the age of eight years, was unable to stand without assistance. The spastic 
contractions and deformities were overcome by tenotomies and by force, and a double 
long spica bandage was applied. This was worn for eight months. It was then replaced 
by the bandage shown in the illustration. Six months later this was removed. There is 
at present no deformity, and the child walks fairly well. 



2. Paraplegia. — The treatment of spastic paraplegia is much 
more difficult than that of hemiplegia, because the disability is 
very much greater and because the mental impairment is usually 
more marked. 

In general, the treatment in infancy is by massage and by 
manipulation. When the child shows a desire to walk an at- 

1 Townsend, Transactions American Orthopedic Association, 1900, vol. xiii. 



632 ORTHOPEDIC SURGERY 

tempt should be made to relieve the spastic contractions. In 
certain instances complete correction of all deformities, followed 
by prolonged fixation of each joint in the overcorrected attitude, 
may be of service (Fig. 404). This may be combined with mul- 
tiple tenotomies if the contractions are more resistant. The 
advantage of tenotomy, aside from the simple correction of de- 
formity, is that by elongation of the tendon the response to the 
exaggerated motor impulses is lessened and an opportunity for 
more effective control is afforded. The beneficial effect of com- 
plete division of contracted parts in checking spasmodic contrac- 
tions is very marked in older patients. 

Tendon Transportation. — Transplantation of tendons from 
the flexor to the extensor aspect of the limb to overcome per- 
sistent flexion of the knee may be of service in certain cases. 
According to the method of Lange, the tendons are exposed by 
incisions on the lower lateral aspects of the knee. They are 
then carried forward beneath the skin and are attached to the 
insertion of the quadriceps extensor tendon, which is exposed by 
a median incision. The actual insertion is usually made by a 
strong cord of silk prolonged from the extremity of each tendon. 
This is necessary to give it sufficient length. The good effect 
of the operation is to be ascribed in all probability in far greater 
degree to the removal of the deforming force than to the extending 
action of the flexor muscles. Except in the very mild cases of 
paraplegia, and as an aid in retaining the limbs in the improved 
position after operative treatment, braces are of little value. 
The trunk is not, as a rule, deformed except in the diplegic cases 
in which the mental impairment is great. Manipulation, massage, 
and posture are of some service in correcting and preventing this 
distortion. 

Prognosis. — It is stated by Peterson 1 that the patients in whom 
the paralysis is paraplegic or diplegic in distribution usually die 
before the twentieth year, and that but few of those in whom 
it is hemiplegic reach the age of forty. This prognosis applies, 
it may be assumed, rather to the extreme cases accompanied by 
mental impairment than to the milder forms. In almost all 
cases the patient, even if idiotic, is finally able to stand and to walk. 
As a rule, there is for a time a gradual improvement in motor 
power and in mental control as well. It is evident that in a class 
in which mental enfeeblement is so common and in which epilepsy 

1 Transactions American Orthopedic Association, 1900, vol. xiii. 



DISEASES OF THE NERVOUS SYSTEM 633 

is present in so large a proportion of cases, moral and mental 
training is of great importance. 

Orthopedic treatment, although it has no direct action upon 
the lesion in the brain, certainly has an indirect effect upon the 
mental as well as upon the physical condition of the patient. 

When deformity has been corrected and when contractions have 
been overcome, functional use requires less mental effort; and 
motor control may be still further improved by drilling the patient 
constantly in simple movements. Such exercises improve the 
motor communications and the ability of the paralyzed part as 
well. 

Spastic Spinal Paralysis. 

Occasionally one encounters cases of spastic paraplegia in 
which there is no cerebral impairment. In such cases the lesion 
appears to be confined to the spinal cord and to be a degeneration 
of the distal portions of the pyramidal tracts due to imperfect 
development. 1 The treatment is similar to the ordinary form of 
spastic paraplegia, but the prognosis is far more encouraging. 

Progressive Muscular Atrophy. 

Progressive muscular atrophy, as the term implies, is a progres- 
sive wasting of the muscles, with corresponding loss of power, 
terminating finally in paralysis and deformity. Its cause is 
apparently some developmental defect. 

Under this title are included two varieties of disease: 

1. The myelopathic form, in which the primary disease is 
apparently of the spinal cord. 

2. The myopathic form, in which the disease appears to be 
primarily of the nerve terminals and the muscular fibres. 

The second variety is usually designated as muscular dystrophy 
to distinguish it from the spinal form. 

Myelopathic Paralysis or Atrophy.— The myelopathic form 
of muscular atrophy, the Aran-Duchenne type, usually begins 
in the small muscles of the hands and spreads from the periphery 
to the trunk. Fibrillary twitching of the affected and unaffected 
muscles is fairly constant, and the reaction of degeneration may 
be present. The disease is practically limited to adults, and 
from the orthopedic standpoint it is of little interest. In another 

1 Spiller, Philadelphia Medical Journal, June 21, 1902. 



634 



ORTHOPEDIC SURGERY 



form, the Charcot-Marie-Tooth type, usually classed with the 
muscular atrophies, the paralysis may begin in the muscles of the 
legs, causing deformity of the equinus or equinovarus variety. 
The lesion of the cord is of the anterior cornua, and resembles 
closely that of the subacute form of anterior poliomyelitis. 

Fig. 405 Fig. 406 





Progressive muscular dystrophy, 
showing the enlargement of the calves 
and the atrophy of the shoulder muscles. 



Progressive muscular dystrophy, facio- 
scapulo-humeral type. Extreme lordosis 
and flexion contractions at the hips. 



Myopathic Paralysis or Muscular Dystrophy. — The myopathic 
form of muscular atrophy may be preceded by apparent hyper- 
trophy (pseudohypertrophic muscular paralysis), it may be pri- 
marily atrophic, or the two forms may be combined. 



DISEASES OF THE NERVOUS SYSTEM 635 

It differs from the myelopathic form in several particulars. 
It is a disease of childhood. It is often hereditary and its dis- 
tribution is different. 

The affection is divided according to the distribution into two 
main varieties: 

1. The facio-scapulo-humeral type (Landouzy-Dejerine), in 
which the muscles of the face and shoulder girdle are primarily 
affected (Fig. 406). 

2. The juvenile form of Erb, in which the muscles of the back 
and of the upper arms are first involved. 

The etiology, pathology, and clinical course of the atrophic 
do not differ essentially from the pseudohypertrophic form. 

Pseudohypertrophic Muscular Paralysis. — Pseudohypertrophic 
paralysis is characterized by progressive weakness of the muscles 
of the trunk and of the legs, associated with apparent hypertrophy 
of the calves due in great part to a deposit of fat in the wasting 
muscles (Fig. 405). 

The symptoms are caused by a degenerative atrophy of the 
nerve terminals and of the muscular fibres and an increase of 
the connective, tissue and replacement of the muscular substance 
by fat. 

Diagnosis. — The interest in this latter affection from the ortho- 
pedic standpoint lies in the diagnosis in the early stage of the 
affection. At this time the patient is evidently weak; he walks 
with an awkward, shambling gait, and climbing stairs is especially 
difficult. There is usually an increased lordosis and a peculiar 
swaying or waddle, a disinclination to stoop, and an evident 
difficulty in regaining the erect posture, and there may be dis- 
comfort or pain referred to the lumbar region. If the disease 
is advanced, the peculiar hard, resistant enlargement of the calves, 
combined, it may be, with atrophy of the muscular groups of the 
upper extremity, and weakness of the muscles of the back, makes 
the diagnosis evident, but in young children the disease may be 
mistaken for Pott's disease, simple weakness, or postural deformity. 
Although there is a superficial resemblance to the general symp- 
toms of Pott's disease, yet the specific signs of disease of the 
vertebrae, pain, and muscular spasm are absent. 

Weakness, a result of malnutrition or disease, is general in 
character and its cause is usually apparent; it is, of course, not 
accompanied by local hypertrophy. Retarded cerebral develop- 
ment causes general weakness as far as inability to stand is con- 
cerned, but the cause is in this class also usually apparent. 



636 ORTHOPEDIC SURGERY 

Postural deformities in childhood always have a cause, and as one 
is not content to treat a deformity without ascertaining its cause, 
this search will bring to light the peculiar symptoms of the disease. 

Treatment. — In certain instances the discomfort referred to 
the back, due in part to the lordosis, may be relieved by a light 
spinal support Massage and muscle-training will enable the 
patient to utilize the remaining power to best advantage. 

In the later stages of the disease there may be secondary defor- 
mities, most marked in the feet, which may be fixed in the equinus 
or equinovarus attitude. This deformity may be corrected by 
tenotomy or otherwise, if the patient has not already become so 
weak that walking or standing is impossible. 

Hereditary Ataxia. Friedreich's Disease. 

Hereditary ataxia is an ataxic paraplegia caused by sclerosis of 
the posterior and lateral columns of the spinal cord. The early 
symptoms are inco-ordination and weakness of the legs; later 
similar symptoms appear in the upper extremities, and speech is 
affected. In well-marked cases there is usually distortion of the 
feet toward equinus or equinovarus, and occasionally a posterior 
or lateral curvature of the spine. In one case recently under 
treatment at the Hospital for Ruptured and Crippled, the recti- 
fication of the deformity of the feet was at least of temporary 
benefit. 

Neuritis. 

Localized neuritis after contagious disease or from other causes 
may result in temporary weakness or paralysis of the dorsal 
flexors of the foot, cause toe-drop, and, finally, deformity. In 
such cases the foot should be supported by a brace in normal 
position. This not only prevents deformity, but it hastens the 
cure by preventing tension upon and structural lengthening of 
the weakened muscles. The same treatment may be applied for 
wrist-drop from metallic poisoning. The hand should be sup- 
ported by a suitable brace in the attitude of dorsiflexion until 
the muscles have recovered their power. Obstetrical paralysis 
has been considered under affections of the shoulder. 

Hysterical Joint Affections and Deformities. Functional 
Affections of the Joints. 

So-called hysterical and functional affections may be divided 
into two groups: 






DISEASES OF THE NERVOUS SYSTEM 637 

1. Those in which there is no actual disease or weakness. 

2. Those in which the symptoms of disease or injury, or of 
their effects, are exaggerated or prolonged. 

The first class of cases is small, the second is large. 

Simulation, whether voluntary or involuntary, of organic dis- 
ease can deceive only those who are not familiar with the char- 
acteristics of the disability that is simulated. Every disease has 
certain well-defined symptoms which can no more be imitated by 
a well person than a disabled part can suddenly take on the 
normal appearance and function. 

"Hysterical Hip." 

The hysterical hip is supposed to simulate actual tuberculous 
disease. 

Diagnosis. — The symptoms of actual disease of this joint are 
pain, limp, limitation of motion due to reflex muscular spasm, 
muscular atrophy, distortion, and in the later stages the local 
signs of a destructive process; for example, heat, swelling, abscess 
and displacement of the parts, shortening of the limb, and the 
like. As these later symptoms could not be simulated, they need 
not be considered. 

In actual disease symptoms and effects follow one another 
in regular sequence and correspond closely to the pathological 
conditions that cause them. Pain is not a pronounced symptom; 
it is more likely to be concealed than exaggerated and it is usually 
referred to the knee. Local sensitiveness is not marked, and it 
is often absent. Distortion of the limb when it occurs in the 
early stage, before the destructive changes are advanced, is caused 
by involuntary muscular contraction, and whenever this dis- 
tortion is great the reflex muscular spasm, which involves every 
muscle about the joint, is also great; so that the range of ny^ion 
in the joint is small, and it may be absolutely restricted. With 
the distortion there is always a corresponding atrophy of the 
muscles of the limb. If pain is present it is usually worse at night 
than during the day. 

The hysterical simulation of hip disease is characterized by an 
exaggeration of the symptoms and by absence of the physical 
signs of disease. There is usually an exaggerated limp, great 
distortion, marked local sensitiveness and pain, but absence of 
muscular spasm, atrophy, or other signs of disease. 

The age of the patient, the history of the supposed disease, and 



638 ORTHOPEDIC SURGERY 

the other evidences of hysteria that are usually present will con- 
firm, the diagnosis. 

The same principle applies, of course, to the differential diag- 
nosis of simulated disease at other joints. The knee and the 
hip-joint are those that are most often involved. 

Hysterical Deformities. 

"Hysterical Club-foot." — Local deformity distinct from simu- 
lated joint disease is sometimes seen. Several cases of this char- 
acter in which the foot was distorted have been under treatment 
at the Hospital for Ruptured and Crippled recently. The differ- 
ential diagnosis is simple. 

Talipes is either congenital or acquired. Congenital talipes 
and all the acquired varieties, other than those of paralytic origin, 
may be at once excluded from consideration. Paralytic talipes 
in the great majority of cases begins in early childhood, when it is 
either caused by anterior poliomyelitis or by cerebral hemiplegia 
or paraplegia. When these are excluded the remaining causes 
of deformity are very limited. Every variety of nervous disease 
has well-defined symptoms. If actual paralysis is present the 
muscles atrophy and the electrical reactions are changed. In 
hysterical contractions the muscles do not atrophy, and the elec- 
trical reactions are unchanged. 

"Hysterical Scoliosis." — A case was at onetime under observa- 
tion at the Hospital for Ruptured and Crippled in which distortion 
of the trunk persisted for more than a year, and until a suit for 
damages was finally decided. In this case there was a most 
exaggerated lateral twist of the spine, so that the shoulder ap- 
proached the pelvis. The deformity, however, was not fixed, 
but it could be completely reduced when the patient was in the 
recumbent posture. There was no paralysis, no persistent spasm, 
no evidence of disease or injury. The deformity was of a nature 
that could not be explained by any conceivable lesion, and other 
signs of hysteria were present. 

Treatment. — The principles of the treatment of pronounced 
hysteria, of which simulated joint disease or deformity are but 
unusual manifestations, are considered at length in medical and 
neurological works, and the subject does not call for special 
mention here. It is evident, of course, that an unequivocal 
diagnosis must be the first and essential step toward cure. In this 
class of cases apparatus is not often indicated unless the deformity 



DISEASES OF THE NERVOUS SYSTEM 639 

lias persisted for so long a time that the disused muscles have be- 
come incapable of performing their proper functions. 

Functional Affections of the Joints. 

"Neurotic Joints." — In this class, although there is no abso- 
lute distinction between it and the preceding variety, there is 
usually a physical basis for the symptoms, however much they 
may be exaggerated. 

The patients are not usually hysterical; in fact, hysteria in 
the ordinarily accepted sense is uncommon, and although the 
larger proportion of patients are women, yet men and children 
are by no means exempt from the so-called functional affec- 
tions. 

It must be borne in mind, also, that many of these cases are 
classed as neurotic simply because the cause of the symptoms is 
not apparent. It is only within a few years that the slighter 
degrees of weak foot and its effects have been recognized, and it 
is probable that such cases, together with anterior metatarsalgia, 
the painful fascia of the contracted foot, achillodynia, and the 
like might be considered as neurotic by one unfamiliar with their 
symptoms. It may be inferred that as diagnosis becomes more 
accurate the more restricted will become the class of cases of 
purely imaginary disability, in so far at least as the locomotive 
apparatus is concerned. 

A "neurotic joint" is often caused by injury. A sprain of 
the ankle, for example, may have been treated by prolonged 
immobilization, either because the patient had originally impressed 
the physician with the severity of the symptoms or because of 
persistent discomfort. When the dressing is removed there may 
be congestion due to impaired circulation, weakness and atrophy 
of the muscles due simply to disuse, and a certain degree of 
infiltration and stiffness caused by the original injury. In cases 
of this character the disability may be prolonged because the 
patient or the physician mistakes the effects of disuse for the symp- 
toms of serious injury or disease. When the diagnosis has been 
made treatment should be directed to increasing the activity 
of the circulation and thus the nutrition of the part, by counter- 
irritation, by massage, by passive movements, by voluntary 
exercises and the like, but cure can only be completed by restoring 
functional use. If, therefore, the disability is of long standing 
a brace may be required for a time to protect the part from injury, 



640 ORTHOPEDIC SURGERY 

and to increase the patient's confidence. In milder cases it is 
possible that without support or treatment, other than an assurance 
of the absence of serious weakness, cure may be accomplished, 
but this is certainly unusual. 

What has been said of exaggerated disability at the ankle fol- 
lowing traumatism applies to the treatment of similar affections 
elsewhere. The knee-joint is very often the seat of so-called 
neurosis. Injury at this point in nervous children is sometimes fol- 
lowed by a persistent flexion contraction that may continue for 
weeks after all signs of the injury have disappeared. When the 
attempt is made to straighten the knee the patient screams with 
pain and the muscular resistance is very great. In such cases 
the immediate rectification of deformity and the application of a 
plaster bandage to hold the limb in the corrected position is 
indicated. It must be borne in mind that the persistent assump- 
tion of a deformed position for weeks or months must be followed 
by certain structural changes in the contracted muscles and weak- 
ness in the opposing groups. Thus some assistance may be 
required in the treatment even of the purely hysterical deformities 
because of this weakness. 

In all forms of traumatic neurosis, so-called, the possibility of 
a physical basis for the symptoms should be considered, the 
location of the pain or discomfort, and its connection with cer- 
tain movements or attitudes should be investigated. If such 
discomfort is induced or is aggravated by a certain motion or 
attitude it is reasonable to infer that this has a well-defined 
cause, especially as the pain of a neurotic affection is not often of 
this definite character. In such cases limitation of the move- 
ments for a time to the painless range of motion by some form of 
support may be indicated. 

Thus far injury has been considered as the starting point of 
the symptoms, but in many cases there is no history of injury. 
In this class the symptoms may have been induced by rheu- 
matism or gout or rheumatoid arthritis, or by neuritis, and such 
possible causes should be investigated and excluded before the 
diagnosis of simple neurosis is made. In neurasthenic patients 
or those who are anaemic, or overworked, the pain and discomfort 
is often localized in the spine. The "neurotic spine" has been 
considered elsewhere. In the treatment of all cases of this group 
the general condition of the patient should receive consideration, 
and in connection with the local treatment a change of occupa- 
tion and of scene is often of advantage. 



DISEASES OF THE NERVOUS SYSTEM 641 

It is hardly necessary to insist again that an accurate diagnosis 
is the first essential of successful treatment. If this is impossible 
at least one may by exclusion of those injuries and disabilities 
and diseases which are evidently not present arrive at a general 
conclusion as to the character of the ailment and shape his treat- 
ment accordingly. 



41 



CHAPTER XIX. 

CONGENITAL AND ACQUIRED TORTICOLLIS. 

Synonym. — Wryneck. 

Torticollis is, as the name implies, a twisted neck, a distortion 
caused in most instances by active contraction or by shortening 
of one or more of the lateral muscles that control the head. 

Similar distortion may be due to disease of the spine, so-called 
false torticollis, but this should be classed as a symptom of the 
underlying disease, not as simple torticollis, of which the distor- 
tion itself is the important disability that demands treatment. 

Torticollis may be divided primarily into two classes: The 
congenital and the acquired. 

Congenital torticollis is a painless shortening of the tissues on 
one side of the neck of intrauterine origin. 

Acquired torticollis is, in most instances, accompanied in its 
early stages by local pain and sensitiveness, and by active con- 
traction of the affected muscles. After a time these acute 
symptoms disappear, leaving simply the deformity. Thus, from 
the therapeutic standpoint, torticollis may be classified as acute 
and chronic, the latter class including the congenital form. 

The sternomastoid is the muscle that is usually involved pri- 
marily, both in the congenital and acquired forms; thus, in typical 
torticollis the head is drawn somewhat forward and is inclined 
toward the contracted muscle, while the neck is pushed, as it 
were, away from the contraction (Fig. 407); the chin is slightly 
elevated, and turned toward the opposite shoulder — an attitude 
explained by the normal action of the affected muscle. Irregular 
distortions of the head, as posterior or anterior torticollis due to 
contraction of muscles other than the sternomastoid, are, however, 
not infrequent. These will be mentioned in the consideration of 
the forms of acquired torticollis. 

Statistics. — Torticollis is comparatively an uncommon defor- 
mity. In a period of twenty-seven years 507 cases were treated 
at the Hospital for Ruptured and Crippled, as contrasted with 
upward of 5000 cases of congenital and acquired talipes. 



CONGENITAL AND ACQUIRED TORTICOLLIS 643 

Acquired torticollis is by far the more common variety, as is 
shown by the fact that of the 507 cases but 87 were supposed to 
be of congenital origin. 

It is often stated that torticollis is more common in males than 
in females, and that the right side is more often affected, yet 46 
of the 87 congenital cases were in females and the contraction 
was of the left side in 38 of the 58 cases in which the affected 
side was specified. Of the entire number of cases available for 
comparison 246 were in females and 198 in males; in 236 instances 
the contraction was on the left and in 196 on the right side of the 
neck. From these statistics it would appear that the deformity 
is somewhat more common in females than in males, and that 
the left side is more often affected than the right. 

Congenital Torticollis. 

In most instances the deformity of congenital torticollis is 
slight at birth, and it may not attract attention until the child 
sits or walks. Thus it is often difficult to distinguish the con- 
genital form from the deformity that may have been acquired 
in infancy, especially as the patient may not be brought for treat- 
ment until the distortion has persisted for many years. 

In early infancy slight torticollis may be demonstrated by 
fixing the shoulder on the affected side and drawing the head 
forcibly in the opposite direction, when the shortened muscle 
becomes prominent beneath the skin, evidently restricting the 
range of motion. In most instances the sternal division of the 
muscle appears to be more shortened than the clavicular portion. 

In exceptional cases the deformity even in infancy may be 
extreme, and it may be accompanied by well-marked asymmetry 
of the face and even by distortion of the skull. In this class 
the shortening may involve all the lateral tissues, both anterior 
and posterior. If asymmetry is present at birth it increases 
somewhat with growth. Even in the acquired form it often 
appears soon after the onset of the deformity, becoming more 
marked with its continuance. Its cause is the constrained attitude, 
the restriction of normal use, and consequently of the blood supply, 
combined with the tension upon the tissues of the face, as is 
evidenced by the fact that it becomes less noticeable after the 
deformity has been corrected. 

In the well-marked cases of long standing, whether congenital 
or acquired, the face is shorter and flatter, the nose and the corner 



644 



ORTHOPEDIC SURGERY 



of the mouth and the eyelids even on the affected side are drawn 
downward, and the skull shows evidence of atrophy and deformity. 

Secondary distortions also appear in the trunk in chronic cases. 
These are rotation of the spine to compensate for the lateral dis- 
tortion of the head and an increase in the dorsal kyphosis, " round 
shoulders." Among the minor secondary deformities upward 
bowing of the clavicle caused by the tension of the contracted 
muscle may be mentioned (Fig. 407). 

In the early stage of torticollis the head is tilted toward the 
contracted tissues, but when the deformity is of longer standing 




Left torticollis, apparently of congenital origin, showing the secondary distortions of 
head and face. 



the head following the compensatory convexity of the cervical 
spine is displaced toward the opposite shoulder (Fig. 408). This 
relieves it from the direct influence of the contracted tissues, con- 
sequently the lateral distortion is less marked. 

The compensatory deformities that have been indicated are 
slight in infancy, but they develop in later childhood, for in many 
instances the shortened muscle ceases to grow; thus, an original 
shortening of half an inch, as compared to its fellow, may be 
increased to two or more inches in later years. This fact em- 



CONGENITAL AND ACQUIRED TORTICOLLIS 



645 



phasizes the importance of treatment as soon as may be possible 
after distortion is discovered. 

As has been stated, the important contraction is usually of the 
sternomastoid muscle, but if the deformity is uncorrected all the 
lateral tissues become shortened. 

Typical wryneck caused by shortening of the sternomastoid 
muscle is by far the most common form of congenital torticollis, 
but occasionally cases are seen in which the head is but slightly 
inclined to one side and in which the shortening appears to involve 
the lateral tissues in general rather than a particular muscle. 




Right torticollis, showing the displacement of the head toward the opposite side, 



In rare instances, although the deformity resembles that of typical 
torticollis, the greatest shortening will be found to be of the 
posterior muscles on one side, particularly of the trapezius and 
the levator anguli scapulae. Thus the scapular may be elevated 
and tilted forward. This form of torticollis appears to be one 
variety of congenital elevation of the scapula. (See page 231.) 
Torticollis due to defective development of the upper extremity of the 
spine is a rare deformity that does not require special description. 

Etiology. — It may be assumed, disregarding the possible influ- 
ence of hereditary predisposition, that congenital torticollis is, in 



646 ORTHOPEDIC SURGERY 

most instances, caused by a constrained or fixed position in the 
uterus for a longer or shorter time before birth. It is, in fact, 
a simple distortion, and that it has, in the majority of cases, no 
deeper significance is proved by the fact that it may be easily 
and completely cured by simple division or elongation of the 
contracted tissues. 

It would seem that a deformity to be properly congenital must 
be present at birth, yet the theory, first advanced by Stromeyer, 
that congenital torticollis is usually the result of injury at birth 
has been so generally accepted that it merits further consideration. 

Haematoma of the Sternomastoid Muscle. — Hsematoma is con- 
sidered to be, and undoubtedly is, evidence of injury. During 
difficult delivery, fibres of the muscle are ruptured, usually in 
the upper or middle third of the anterior border, hemorrhage 
follows, which in turn is surrounded by an encapsulating area of 
inflammatory material. This forms a firm, cylindrical tumor in 
the substance of the muscle, which becomes noticeable about two 
weeks after birth, or at least this is the time when it is usually 
discovered by the mother. As a rule, the tumor is not sensitive 
to pressure; it may or may not be accompanied by restriction of 
motion in the direction causing tension on the muscle. The 
tumor remains for from three to six months, when it usually 
disappears, leaving no trace of its presence. 

The theory of Stromeyer, which until recently was generally 
accepted, is that congenital torticollis is usually caused by rupture 
of the muscle and by myositis about the hsematoma. This inflam- 
mation may involve and ultimately destroy a large part of the 
substance of the muscle, replacing it with fibrous tissue, which, 
contracting, causes deformity. 

This theory is extremely improbable for the following reasons: 

1. Rupture of muscle elsewhere is practically never followed 
by myositis and contraction. 

2. It has been demonstrated by Heller 1 that it is impossible 
to cause myositis and contraction by any form of injury to the 
muscles of animals unless it be combined with actual infection 
with pyogenic germs. 

3. Most of the cases of congenital torticollis seen soon after 
birth present no evidence of hsematoma or injury, viz. : In 7 of 55 
cases of supposed congenital torticollis, investigated by the writer, 
there was a history of injury at birth. In 48 cases no mention 
was made of injury. In the 7 cases referred to the deformity was 

1 Heller, Deutsch. Zeits. f. Chir., Bd. xlix., H. 2 and 3. S. 234. 



CONGENITAL AND ACQUIRED TORTICOLLIS 647 

accompanied by hsematoma or there was a history of a swelling, 
apparently of this nature; but in 2 of these the hsematoma was 
coincident with intrauterine shortening of the muscle. 

4. Cases of hsematoma of the sternomastoid muscle are not, as 
a rule, followed by torticollis. Seven consecutive cases of hsema- 
toma were examined by the writer with special reference to this 
point. In all the evidence of violence in delivery was clear. 
Two were delivered by forceps, 3 were breech presentations, 
and in 2 version was performed. In 1 case an arm was broken 
and in another paralysis resulted from injury to the brachial 
plexus. Six of the children lived until the swelling had nearly 
or entirely disappeared, and in none did torticollis accompany 
or follow the hsematoma. 

5. In certain cases a congenitally shortened muscle may be 
ruptured at delivery; thus the hsematoma is simply a complica- 
tion of torticollis, not its cause. Brans 1 has reported such a 
case, and two others have been observed by the writer, in one of 
which club-foot was present also. 

6. Hard tumors of the sternomastoid muscle are not always 
the result of injury; myositis may be of syphilitic origin appar- 
ently occurring in intrauterine life. In other instances tumors 
of fibrous or sarcomatous nature have been removed from the 
substance of the muscle. Sixteen cases in which cartilaginous 
nodules, apparently of congenital origin, were found in the muscle 
have been reported. 2 

One may conclude then that congenital torticollis in the majority 
of cases is of intrauterine origin. If it follows injury at birth 
it is probably an indirect result of local pain, discomfort, and 
irritation of the nerves or of an actual infectious inflammation of 
the injured part rather than an effect of the absorption of effused 
blood. 

Pathology. — In the ordinary type of congenital torticollis, as 
demonstrated at operations on children, the substance of the 
affected muscle or muscles is simply lessened in amount, and there 
is a disproportionate area of tendinous substance as compared 
to the contractile tissue. In other instances the muscle may be 
almost entirely replaced by fibrous tissue or it may be traversed 
by fibrous bands, or patches of scar-like tissue may be distributed 
throughout its substance. These degenerative changes, consid- 
ered to be evidences of pre-existing myositis, are probably more 
common among the acquired than the congenital form, and, as a 

1 Zent. f. Chir., 1891, No. 26. 2 Leugemann, Beitr. z. klin. Chir., Bd. xxx., H. 1. 



648 ORTHOPEDIC SURGERY 

rule, they are found only in cases of long standing. Secondarily 
all the lateral tissues of the neck are shortened to correspond to 
the habitual attitude, and the compensatory curvatures of the spine 
in time become fixed, so that torticollis may be classed as one of 
the causes of scoliosis. 



Acquired Torticollis. 

Acquired torticollis is an affection of early life, at least 80 per 
cent, of the cases beginning in the first ten years of life. 

As has been stated, congenital torticollis is usually a painless 
shortening of the muscles, while acquired torticollis is, as a rule, 
a painful affection secondary to injury or disease of some of the 
structures of the neck, which causes irritation of the peripheral 
nerves and active contraction of the neighboring muscles. Thus, 
as a rule, the number of muscles involved in the deformity is 
greater than in the congenital form; for example, in the ordinary 
form of acquired wryneck both the trapezius and the sterno- 
mastoid are contracted ; and irregular forms of distortion caused 
by spasm of other muscular groups are not uncommon. 

Varieties. — The varieties of acquired torticollis may be clas- 
sified conveniently as follows : 

1. The simple or mechanical form due to scar contraction fol- 
lowing destruction of the skin or deeper tissues, as from burns 
or disease. 

2. Acute torticollis caused by direct irritation of the muscle, 
by injury, by inflammatory affections of the surrounding parts, 
combined in most instances with irritation of the peripheral 
nerves, which causes reflex contraction of certain muscles or 
muscular groups. 

3. Spasmodic Torticollis. — A form of convulsive spasm, "a dis- 
order of the cortical centres for rotation of the head." (Walton.) 

4. Irregular Forms of Torticollis. — Paralytic, ocular, psychical, 
and the like. 

The first class, that due to scar contraction, needs only to be 
mentioned. 

Etiology of Acute Torticollis. — The second class is the most 
important form of torticollis, both as to frequency and as to its 
effect in causing permanent distortion. Of this group, one of the 
most common and at the same time the least important form is 
the simple stiff neck, supposed to be due to cold or to muscular 
rheumatism. Its onset is, in childhood, sometimes accompanied 



CONGENITAL AND ACQUIRED TORTICOLLIS 649 

by slight fever and malaise; the affected muscle is somewhat 
sensitive to pressure and motion or tension causes discomfort. 
The distortion, in great part voluntary and accommodative, is of 
short duration as a rule. Strains and direct injury of the muscles 
of the neck may cause deformity, which usually disappears when 
the local sensitiveness has subsided. Traumatic hsematomata, 
similar to those caused by injury at birth, are sometimes observed 
in older subjects. These usually disappear after a time, leaving 
no trace of their presence. 

Another form of torticollis is secondary to cellulitis and to in- 
filtration following the breaking down of tuberculous cervical 
glands. This may become a permanent distortion if the defor- 
mity is allowed to persist or if the tissues of the neck are injured 
by the suppurative process. 

By far the most important variety of this class is the acute 
spastic torticollis due to active tonic contraction of one or more 
of the muscles of the neck. The exciting cause of the spasm 
appears to be irritation of the peripheral nerves in the naso- 
pharynx or in its neighborhood, and the muscles most often 
affected are those supplied in part by the spinal accessory nerve. 
Thus, torticollis of this form may follow tonsillitis, pharyn- 
gitis, measles, diphtheria and the like. It may be preceded by 
"toothache" or "earache," or it may be an accompaniment of 
what appears to be the ordinary form of stiff neck or of enlarged 
or suppurating cervical glands. In this form the torticollis is 
caused directly by tonic contraction of the muscles. Reflex spasm' 
of this character is, however, often associated with distortion, 
due primarily to injury of the neck or to some local inflammatory 
process, so that a sharp distinction between the divisions of this 
second class is impossible. Many of the patients are known to be 
of a nervous temperament, and overstudy, anxiety, sudden shock, 
and the like are considered to be predisposing causes. 

This variety of acquired torticollis completely overshadows in 
importance all other forms, as is indicated by the statistics of 212 
cases treated at the Hospital for Ruptured and Crippled, in which 
the cause seemed to be apparent. Of the 212 cases 181 may be 
fairly assigned to this class. 

The apparent exciting causes of cases of acquired torticollis 
treated at the Hospital for Ruptured and Crippled are shown in 
the following table: 



650 ORTHOPEDIC SURGERY 





. 14 

. 41 

. 14 

7 

6 














18 








1 








6 




Malaria 

Injury by the neck 






Measles 


2 
8 
3 
6 
2 
1 

h chorea , 
epilepsy 
cortical 
hysteria 
meningi' 
hemiple 


35 
3 


Suppurative otitis .... 

Toothache 

Cellulitis of the neck . 
Furuncle " " ... 


Syphilis 

Cicatricial contraction . 

Total .... 


4 
1 
5 
1 
1 
3 
8 
. 8 

. 31 


1 
3 

181 




irritation 

tis 

gia 














Total 





Symptoms of Acute Torticollis. —As a rule, the distortion of 
the neck, slight at first, is more noticeable at night than in the 
morning; it then gradually increases until the deformity becomes 
fixed. In other instances the onset is sudden, sometimes accom- 
panied by fever. 

As has been stated, in most instances several muscles are more 
or less involved in the contraction, particularly the sternomastoid 
and the trapezius, and in such cases the deformity is more marked 
and persistent than when the sternomastoid is alone affected. 
Less often the contraction is of the posterior group, "posterior 
torticollis" (Fig- 411), when the head is tilted backward and the 
chin is turned more toward the opposite side than in the typical 
lateral form. In other cases the contraction appears to affect the 
small muscles that control the joints at the upper extremity of the 
spine, when the head may be tilted forward with but slight lateral 
inclination, resembling closely, except in the history, the symp- 
tomatic wryneck of Pott's disease. In rare instances the muscles 
on both sides of the neck may be contracted simultaneously 
(Fig. 409). The contracted muscles are usually sensitive to 
manipulation and attempted rectification of the deformity causes 
extreme pain and is resisted by the patient. The child is, as a 
rule, nervous and irritable; it often complains of neuralgic pain 
about the contracted parts, which is increased by sudden or, 
unguarded movements or strain; thus "getting the patient to bed' 
is often a tedious proceeding, because of the difficulty of supporting 
the head comfortably with the pillows. 

In many instances the affection is of short duration; in others 



CONGENITAL AND ACQUIRED TORTICOLLIS 



651 



particularly those in which the reflex spasm is aggravated by 
local inflammatory processes, there appears to be but little ten- 
dency toward recovery. In such cases, after several weeks or 
months, the local pain and sensitiveness may subside, together 
with the active spasm, but the deformity, caused by adaptive 
shortening of the muscles and fascia, aggravated in some instances 
by actual myositis, persists. The muscles atrophy and degen- 
erate and present at a later stage the same pathological appear- 
ances that are found in the congenital form. 

Diagnosis. — Torticollis is most often confounded with Pott's 
disease. This would seem to be hardly possible in cases of the 

7 Fig. 409 Fig. 410 




Bilateral contraction of the sternomastoid 
and trapezii muscles. (See Fig. 410.) 



Bilateral torticollis after treatment. 
(See Fig. 409.) 



simple painless contraction of chronic torticollis. In the acute 
form, however, there may be more difficulty in distinguishing 
between the two. The main points have been mentioned already 
in connection with Pott's disease. In acute torticollis the affec- 
tion is of sudden onset, not preceded by the stiffness and neuralgic 
pain that characterize tuberculous disease. The deformity of 
torticollis is almost always of the regular type — that is, the head 
is tilted toward the contracted muscles while the chin is rotated 
in -the opposite direction. The spasm and contraction of the 



052 OB THOPEDIC SURGERY 

affected muscles are apparent, and direct tension upon them is 
painful. If, however, the tension is relaxed by inclining the 
head toward the contraction, movement of the head in other direc- 
tions will be found to be practically unrestricted. 

In Pott's disease the spasm of muscles is general, the deformity 
is not of a regular type, since the chin often points to the side 
toward which the head is inclined. Steady tension with the aim 




Posterior torticollis. Duration one week. 

of reducing the deformity is not, as a rule, painful; in fact, it is 
often agreeable to the patient. Finally, the limitation of motion 
cannot be lessened by inclining the head toward the muscle that 
seems to be most contracted, for the reflex spasm of Pott's disease 
limits motion in every direction. As a rule, the diagnosis is 
easily made, but in cases complicated by suppuration of the cer- 
vical glands it is sometimes impossible to exclude Pott's disease 
until after the effect of treatment has been observed. 



CONGENITAL AND ACQUIRED TORTICOLLIS 653 

Disease of the cervical spine, other than tuberculous, is com- 
paratively rare, and resembles in its symptoms Pott's disease 
rather than torticollis. Arthritis of the suboccipital articulations 
may be a manifestation of rheumatism; it may follow infectious 
disease, or it may occur as an isolated infection. It is of sudden 
onset, and it resembles acute spastic torticollis, except that all the 
surrounding muscles are affected rather than a particular group; 
in fact, but for the history it could not be distinguished from 
tuberculous disease of this region. 

Although the diagnosis of torticollis is simple, it is not always 
easy to determine the muscle or muscles involved in the contraction. 
The effect of unilateral contraction of the different muscles is as 
follows : 

The sternomastoid inclines the head toward the contraction, 
displaces it toward the opposite shoulder, elevates the chin, and 
turns it away from the contracted muscle. 

The trapezius has much the same action, but the backward 
inclination and rotation are more marked. 

The action of the complexus resembles that of the trapezius, 
but the rotation is less. 

The splenius inclines the head backward and toward the con- 
tracted muscle, but does not turn the chin in the opposite direction. 

The scaleni have the same action, except that the head is inclined 
forward. 

As has been stated, in acute torticollis several muscles are 
often involved, but the spasm is usually greater in one or in one 
group than in another. The seat of greatest contraction may be 
determined by the deformity, by the evident spasm that resists 
reposition, and by the local sensitiveness on palpation. As a 
rule, when the primary contraction is of the posterior group the 
deformity is more marked than in other forms. Bilateral contrac- 
tion of the muscles is rare, but it is occasionally seen (Fig. 409). 

Treatment. — The treatment varies according to the cause and 
with the duration of the deformity. Excluding, for the present, 
the rare and irregular forms of wryneck there are, from the re- 
medial standpoint, two forms of torticollis: 

1. The chronic form, in which the local pain and sensitiveness 
are absent, but in which there is resistant and permanent defor- 
mity. As has been stated, congenital torticollis is included in this 
class. 

2. The acute form, in which the distortion is of short duration 
and in which permanent contraction may be prevented. 



654 OB THOPEDIC 8 URGEB Y 

The Treatment of Chronic Torticollis. By Manipulation. — Con- 
genital torticollis, if of moderate degree, can be overcome in early 
infancy by methodical stretching of the contracted parts. One 
person fixes the arm and another draws the head gently but firmly 
in the direction opposed to the contraction, over and over again, 
meanwhile massaging the tissues of the neck. The procedure 
should be repeated several times a day; it causes slight momentary 
discomfort if properly performed, but this ceases when the stretch- 
ing is discontinued. Care should be taken also that the posture 
may, as far as possible, favor the reduction of the deformity; 
thus while the child is in the mother's arms the head should be 
supported, and when asleep the pillow may be arranged in a 
manner to prevent the improper position. In this way the torti- 
collis may be entirely corrected or its progress may be checked 
until more effective treatment is indicated. 

Haematoma.— This should be treated by massage with some 
bland ointment; if it is accompanied by deformity the manipula- 
tion already described should be employed. 

In the great majority of cases of congenital torticollis the patient 
is not brought for treatment until the deformity has become 
an eyesore to the parents. The contracted muscle is then usually 
an inch shorter than its fellow, the disparity increasing, as a rule, 
with the growth of the child. In such cases the immediate correc- 
tion of the deformity is indicated, and this implies in most instances 
division of the contracted parts by subcutaneous tenotomy or by 
open incision. 

By Subcutaneous Tenotomy. — If the deformity is comparatively 
slight and if the contraction seems to be limited to the sterno- 
mastoid muscle, and particularly to its sternal portion, one may 
hope to overcome the most resistant part of the contraction by 
the subcutaneous operation. Aside from the possibility of wound 
infection, which at the present time is an argument of very little 
weight, subcutaneous tenotomy has the advantages of simplicity, 
apparent freedom from the danger which parents associate with 
an operation, and it leaves no scar behind. It is inadequate, 
however, for the correction of advanced cases. 

The patient and the instruments having been prepared as for an 
ordinary operation, a sand-bag is placed beneath the shoulders and 
the head is inclined so that the contracted muscle is thrown into 
relief beneath the skin. The sternal insertion of the tendon is 
seized with two fingers and the tenotome is inserted beside it and 
passed beneath it at a point about an inch above the sternum. 



CONGENITAL AND ACQUIRED TORTICOLLIS 655 

It is then divided by a sawing motion of the knife. Division of 
this part of the muscle in this situation is practically free from 
danger, and in the slighter degrees of deformity one can by vigor- 
ous manipulation and forcible traction overcome the resistance 
offered by the other tissues. If bands of fascia resist the correc- 
tion, they may be divided by superficial nicking with the tenotome 
in the lateral region of the neck. As a rule, however, in cases 
of this type the open incision is to be preferred, as it allows the 
opportunity for free division of the contracted parts with less 
danger of injury to the bloodvessels and nerves in this neighbor- 
hood. 

By the Open Method. — The incision should be made just above 
the clavicle in the line of the muscle midway between the sternal 
and clavicular insertion. In the milder cases in childhood it need 
be little more than an inch in length. A director may be passed 
beneath the tendon, and on this it may be divided. The clavic- 
ular insertion and the more resistant bands of fascia may be 
divided as they appear. 

In cases of very great deformity in the adult some of the pos- 
terior as well as the lateral muscles are involved. In such instances 
the contracted parts may be divided at the upper border of the 
neck through an incision from the mastoid process backward 
along the lower border of the scalp, the scar being concealed by 
the hair. 

Overcorrection of the Deformity. — The object of treatment is not 
only to straighten the head, but also to overcome all restric- 
tion of motion that may remain after the division of the more 
resistant parts, and the operation, whether open or subcutaneous, 
must be supplemented by a vigorous, methodical stretching of 
underlying resistant tissues. Finally, the head should be rotated 
in the opposite direction, the aim being to completely overcome 
the secondary curvature of the cervical spine. 

It may be stated that Lorenz considers it possible to correct 
torticollis, even of long standing, by systematic kneading and 
stretching without previous division of the contracted tissues, but 
the use of so much force appears to be undesirable if by so slight 
an operation it may be avoided. It is because the after stretching 
is so important that the upright incision is to be preferred to one 
in the line of the clavicle. 

After all resistance to passive motion has been overcome 
by vigorous manipulation the head should be fixed during the 
process of repair in the overcorrected position. Thus in the 



656 



ORTHOPEDIC SURGERY 



treatment of typical torticollis the chin should be turned to a 
point over the middle of the clavicle on the operated side, and 
the head should be inclined toward the opposite shoulder, while 
the neck is held in the median line. In this attitude a plaster 
bandage should be applied surrounding the head and the thorax. 
It should remain until all local sensitiveness has disappeared, and 
until the tendency toward deformity has been checked. Fixation 
in the overcorrected position is very important in childhood, as 
an aid in overcoming the deformity habit, but it may be dispensed 
with in the treatment of adults (Fig. 412). 




Torticollis, left, showing the method of fixing the head in the overcorrected position. 
After operation. 



The plaster bandage is usually retained from four to eight 
weeks. When it is removed, massage, manipulation, and gymnastic 
training are indicated. Twice a day the head should be forced to 
the extreme limit of overcorrection. Traction on the neck in 
self-suspension by means of the sling used in the application of 
the plaster jacket, a regular system of exercises for the muscles 
of the neck and back, and supervision of the habitual postures will 
usually assure a complete cure. If, however, the deformity habit 



CONGENITAL AND ACQUIRED TORTICOLLIS 657 

is strong so that the head has a marked tendency to resume the 
former attitude, some support is indicated. A simple and effec- 
tive support is the jury-mast as used in the treatment of Pott's 
disease with the plaster jacket or attached to a brace- In the 
treatment of children a band of elastic tape arranged to draw the 
head toward the shoulder as suggested by Sayre, or a Thomas 
collar, may be sufficient. 

As has been stated, the necessity for support, provided the 
deformity has been thoroughly overcorrected, depends upon the 
care that is to be exercised in the after-treatment. When exer- 
cises and massage can be efficiently employed, the support is not 
essential. In other cases it may be worn for several months with 
advantage. 

The principles of the treatment of the chronic or painless form 
of torticollis that have been outlined apply to the acquired as 
well as to the congenital form, when adaptive shortening has 
replaced active contraction. Acquired torticollis is, in most 
instances, however, a preventable deformity; thus operative 
treatment would be rarely required had the patient received 
proper treatment. 

The Treatment of Acute Torticollis. — The insignificant form of 
torticollis called stiff neck may be treated by hot applications; a 
firm, thick collar of flexible cotton stiffened by several layers of 
adhesive plaster is an agreeable support in the more painful cases. 

In acute spastic torticollis the cramp-like contraction of the 
muscles is secondary to irritation elsewhere. This, one should 
always try to remove, and, as has been stated, the general con- 
dition of the patient often requires treatment as well. But the 
important indication is to support the head in order to relieve the 
pain and to correct the distortion. In the early stage the support 
of the collar that has been described may be sufficient, but, as a 
rule, patients of this class are not seen until the distortion has 
persisted for weeks or months even, so that a more efficient 
form of support is required — such is the plaster jacket and jury- 
mast. The elastic tension of this appliance overcomes the 
spasm and relieves the discomfort and apprehension which have 
lowered the vitality of the patient (Fig. 51). If the spasm is 
the result of the irritation of enlarged or suppurating cervical 
glands, as is often the case, the rest afforded by the brace is an 
effective treatment of the cause as well as of its effect, and if 
suppuration is present this support is most convenient for the 
dressing that may be required. When the acute symptoms and 

42 



658 ORTHOPEDIC SURGERY 

the deformity have been relieved, manipulation and exercises may 
employed in the manner already described. 

In cases of longer standing, particularly when the posterior 
muscles are involved, the deformity may be forcibly corrected 
under anaesthesia, and the head may then be fixed in a plaster 
dressing in the manner already described. This treatment may 
be employed at an earlier stage in selected cases. As a rule, 
when deformity has been allowed to persist for six months or more, 
its rectification will require division of the more resistant tissues. 

Spasmodic Torticollis. 

Spasmodic torticollis, a form of convulsive spasm of the 
muscles of the neck that is somewhat similar in its general char- 
acteristics to writer's camp, 1 must not be confounded with the 
acute torticollis of childhood, in which tonic spasm of the affected 
muscles, due usually to some well-defined irritation of the 
peripheral nerves, is the characteristic. Spasmodic torticollis is 
an affection of adult life. Of 32 cases collected by Richardson 
and Walton, 2 but two were in patients less than twenty years of 
age. The sexes are equally liable to the affection, and the con- 
traction is as frequent on one side as on the other. . 

The onset of the affection is usually gradual. The first symp- 
toms are usually of stiffness and discomfort in the muscles 
of the neck; a "drawing sensation" and a momentary twitch- 
ing or slight contraction which draws the head to one side. 
These symptoms increase slowly until the head is habitually 
inclined in the attitude of torticollis. For a time the patient can 
correct the position voluntarily, or by supporting the head with 
the hand can restrain the twitching of the muscles, but in well- 
established cases the head is persistently inclined to one side and 
the convulsive spasm is uncontrollable. This latter symptom is 
the most marked peculiarity of the affection; at intervals the muscles 
begin to twitch, and the head finally drawn by the convulsive 
contraction into an attitude of extreme deformity. As the muscles 
most often affected are the sternomastoid and trapezius the 
attitude is usually one of typical torticollis. The spasmodic 
clonic contractions may involve the muscles of the face or of 
the chest even. They are more marked when the patient is 
excited or when sudden movements are necessary. As a rule, 

1 Spasmodic torticollis is defined by Walton as a "disorder of the cortical centres for 
rotation of the head," American Journal of the Medical Sciences, March, 1898. 
3 American Journal of the Medical Sciences, January, 1895, 



CONGENITAL AND ACQUIRED TORTICOLLIS 659 

patients complain of neuralgic pain in the head and neck, aggra- 
vated by the cramp-like contractions. 

Etiology and Pathology. — The etiology is obscure. Many of 
the patients present a neurotic family or personal history, and 
overwork, shock to the nervous system, and the like are cited as 
predisposing causes. The affection has been compared to writer's 
cramp, as in certain instances the spasm appeared to be caused by 
constrained positions of the head necessitated by certain occupa- 
tions, aggravated, it may be, by the strain of defective eyesight. 

The affected muscles may be hypertrophied from constant 
activity, and in the later stages of the affection they are, as a 
rule, permanently shortened. No characteristic changes in the 
nerves or in the central nervous system have been recorded. 

Prognosis. — There is little tendency toward spontaneous re- 
covery. As a rule, the spasm becomes more constant and other 
muscles become involved. 

Treatment. — It is perhaps unnecessary to state that the general 
condition of the patient and the possible local and general causes 
of the spasm should receive consideration. As a rule, however, 
the patient will have exhausted both constitutional and local 
treatment before coming under observation. 

In the mild and early cases the avoidance of predisposing 
causes combined with massage, systematic muscle training, and 
in exceptional instances mechanical support may be of service; 
but in the chronic, severe, and persistent cases of this class the 
resection of nerves supplying the affected muscles has alone proved 
to be efficient. If the spasm is limited to the sternomastoid and 
trapezius muscles, resection of the spinal accessory nerve may be 
sufficient; but if other muscles are involved or if the spasm recurs 
after the original operation, the removal of the posterior branches 
of the upper cervical nerves, together with extensive division of 
the contracted muscles upon the same side and sometimes upon 
the opposite side also, may be required. 

Resection of the spinal accessory nerve was first performed by 
Campbell de Morgan, of London, in 1866, and since then the 
operation has been repeated many times by other surgeons, with 
temporary or permanent benefit to the patients. According to 
Petit, of 26 patients so treated 13 were cured and 7 were perma- 
nently improved. In 5 others the benefit was but temporary, 
and 1 died from erysipelas following the operation. 1 

1 L'Union fttedicale, July 9, 1897. 



660 ORTHOPEDIC SURGERY 

The Operation. — The spinal accessory nerve passes downward 
and backward from the jugular foramen and enters the anterior 
border of the sternomastoid muscle at a point about one and a 
half inches below the tip of the mastoid process. At this point 
it should be exposed. Dr. E. Eliot, Jr., from a special study of 
the course and relations of the nerve, suggests the following 
method: 1 

"The incision should be generous, for the nerve is situated at 
a considerable depth, and should extend from the mastoid process 
above downward to one or two inches beyond the angle of the 
jaw. The anterior edge of the sternomastoid should then be 
exposed. In the upper part of the wound the posterior and 
inferior portion of the parotid gland may have to be drawn for- 
ward, although usually it does not overlap the muscle. When 
this is done it is comparatively easy to expose by blunt dissection 
the transverse process of the atlas, as it lies directly below the 
mastoid process above, while immediately in front of this bony 
prominence, and running downward and forward from the mas- 
toid process toward the angle of the jaw is the posterior belly of 
the digastric. Behind this lie the main vessels of the neck, with 
the spinal accessory nerve emerging from the jugular foramen, 
and the operator is certain that no harm can be done to these 
structures as long as he remains superficial to the digastric belly, 
which in its turn lies at a considerable depth — in fact, at about 
the level of the transverse process of the atlas. 

"Owen and Petit have drawn attention to the fact that the 
nerve usually enters the mastoid muscle at a point opposite the 
angle of the jaw. I have found, however, in a large majority of 
cases that, on leaving the internal jugular it assumes a definite 
relationship with the transverse process of the atlas. Never 
above it, sometimes directly over it, usually a fraction of an inch in 
front of its most prominent part, the nerve may easily be detected 
in the small amount of connective tissue that envelops it, and 
from this point to its entrance into the belly of the muscle it may 
be isolated with safety, and treated by any suitable procedure. 
If, exceptionally, it should escape detection the anterior border 
of the muscle should be drawn sharply backward at a point oppo- 
site the angle of the jaw, the nerve in this way put on the stretch, 
and by blunt dissection in the adipose tissue that separates the 
under surface of the muscle from the sheath of the vessels 
the nerve may be readily exposed. Usually the nerve passes 

1 Annals of Surgery, May, 1895. 



CONGENITAL AND ACQUIRED TORTICOLLIS 661 

from under the posterior belly of the digastric, at a point just 
in front of the transverse process of the atlas, to a point on the 
deep surface of the muscle just behind its anterior margin oppo- 
site the angle of the inferior maxilla. It is sometimes accom- 
panied by a small artery and vein, the latter easily visible, the 
former a branch of the occipital. Rarely the nerve lies at a con- 
siderable distance from the transverse process of the atlas; in one 
case as much as half an inch anteriorly. Here the nerve could 
be found at its entrance into the muscle, the landmark of the 
transverse process having failed to localize its situation." 

Richardson suggests that if the nerve is not readily found its 
position may be ascertained by drawing the finger-nail firmly 
across the bottom of the wound, a sharp contraction following 
pressure upon it. The nerve having been isolated a section of an 
inch should be removed. Richardson advises in addition vigor- 
ous stretching of both extremities. After division of the nerve 
the spasmodic contraction relaxes and the muscles become flaccid, 
allowing the head to be brought to the normal position, or if the 
deformity has become permanent the contracted parts may be 
divided as in the ordinary form. Fixation of the head is not, as 
a rule, required. The operation should be supplemented by 
massage and by muscle-training. If the spasm has been confined 
to the muscles supplied by the spinal accessory nerve, the treat- 
ment may be permanently successful, but in many instances the 
spasm may recur in other muscles. Of these, the posterior group 
of the opposite side is more often affected, and a similar opera- 
tion for resection of the posterior branches of the upper cervical 
nerves may be indicated. This has been performed with success 
by Smith, of London; Keen, Richardson, and others. According 
to Smith, 1 the operation should be conducted as follows: An 
incision is carried downward from the occiput about three inches 
in length, parallel to and one inch from the spinous processes. It 
is continued through the trapezius to the edge of the splenius. 

The complexus is then divided and the posterior branches of the 
nerves are exposed; those of the three upper nerves which supply 
the posterior rotators are then resected. 

Keen 2 operates in a somewhat different manner, by a transverse 
incision two and a half inches in length from the middle line of 
the neck on a level with a point one-half an inch below the level 
of the lobule of the ear. The trapezius is divided transversely, 
afterward the complexus, care being taken to spare the great 

1 Spasmodic Wryneck, London, 1891. - Annals of Surgery, January, 1891. 



662 ORTHOPEDIC SURGERY 

occipital nerve. The posterior branch of the second cervical 
nerve is then resected; the suboccipital nerve is then looked for 
in the suboccipital triangle, traced down to the spine, and divided. 
The external trunk of the posterior division of the third occipital 
nerve is then exposed below the great occipital and divided close 
to the bifurcation of the nerve trunk; thus the nerve supply of 
the chief posterior rotators, the splenius capitis, the rectus capitis, 
posticus major, and the obliquus inferior is removed. 

The paralysis that follows even such extensive operations 
seems to inconvenience the patient but slightly, while the relief 
from deformity and from the constant spasm is a more than suffi- 
cient compensation for whatever weakness or disability may result. 

The following are the conclusions of Richardson and Walton: 1 

1. Palliative treatment, whether by drugs, .apparatus, or elec- 
tricity, will rarely prove successful in well-established spasmodic 
torticollis. 

2. Massage may prove of value in comparatively recent cases. 

3. Resection affords practically the only rational remedy. 

4. Operation on the spinal accessory nerve may afford relief, 
even if other muscles than the sternocleidomastoid are affected. 
On the other hand, the affection previously limited to the sterno- 
cleidomastoid may spread to other muscles in spite of this opera- 
tion. 

5. No fear of disabling paralysis need deter us from recom- 
mending operation, as the head can be held erect even after the 
most extensive resection. 

6. The most common combination of spasm is that involving 
the sternomastoid on one side and the posterior rotators on the 
other, the head being held in the position of sternomastoid spasm 
with the addition of retraction through the greater power of the 
posterior rotators. 

7. It seems advisable in most cases to give preference to the 
resection of the spinal accessory as the preliminary procedure. 

In a later communication Richardson and Walton 2 report very 
satisfactory final results on cases treated by resection of nerves 
supplying the muscles that were affected by the spasm on one or 
both sides, combined with complete division of the muscles as 
well, when permanent contraction was present. 

Kalmus 8 has reviewed the literature of the subject. In 11 
cases of simple stretching of the spinal accessory nerve 3 were 

1 Annals of Surgery, January, 1891. 

2 American Journal of the Medical Sciences, 1896. 

3 Zur Operativ Behand. Caput. Obst. Spasticum, Beitrage zur klin. Chir., 1900, Bd. xxiv. 



CONGENITAL AND ACQUIRED TORTICOLLIS 663 

cured. In 68 cases the nerve was resected; of these 23 were 
cured and 20 were improved. In 4 there was no improvement 
and in 1 the patient died. In 15 cases the resection of the nerve 
was supplemented by division of cervical nerves; 10 of these 
were cured and 3 were improved. In 2 others the sternomastoid 
muscle was divided. 



Irregular and Exceptional Forms of Torticollis. 

Paralytic Torticollis. — One or more of the muscles of the neck 
may be paralyzed, as from anterior poliomyelitis, and thus a 
deformity, due at first to simple weakness and later to the 
permanent effects of the disability, may be the result. 

Diphtheritic Paralysis and Torticollis. —The muscles of the 
neck may be involved in paralysis following diphtheria. In this 
form the trapezii muscles are, as a rule, affected, so that the head 
droops forward, but occasionally the paralysis may be accompanied 
by contraction of one of the sternomastoids. The history, the 
evident weakness, and the paralysis of the soft palate or other 
parts, which is often present, usually make the diagnosis clear. 

Cervical Opisthotonos. — In the course of certain forms of dis- 
ease of the nervous system, for example, cerebrospinal or basilar 
meningitis, the head may be drawn backward by spasm of the 
posterior muscles. A slight degree of the same deformity is 
sometimes seen in ill-nourished infants not suffering from serious 
disease. This and the preceding distortion are of some impor- 
tance, because they may be mistaken for symptoms of Pott's 
disease and they have been described in that connection. (See 
page 62.) _ 

Rhachitic Torticollis. — During the course of acute rhachitis, 
particularly when the characteristic deformity of the lower part 
of the spine is well-marked, the head may be tilted backward 
usually as a compensatory attitude, but occasionally slight spasm 
of the posterior muscles may increase the distortion; so, also, 
when lateral deviation of the spine is present due to rhachitis the 
neck may participate in the deformity as in other forms of rotary 
lateral curvature. This is not torticollis, however, in the proper 
sense. 

Ocular Torticollis. —Several cases have been recorded in which 
the head was habitually held in a distorted attitude because- of 
defective vision or irregularity in the action of the muscles of the 



664 ORTHOPEDIC SURGERY 

eyes. This is, however, rather an improper attitude than a 
variety of true torticollis 1 (Fig. 169). 

Psychical Torticollis. — A distortion of the head, apparently 
due to the inability of the patient to control the muscles of the 
neck, has been described by Brissaud. 2 The deformity is not 
due to muscular spasm, since it can be corrected by the pressure 
of a finger on the head. The condition is called by Brissaud a 
local paralysis of the will — a form of neurosis allied to neuras- 
thenia, epilepsy, and functional spasm. 

1 Medical News, June 11, 1898. p. 772. 2 These de Paris, 1894. 



CHAPTER XX. 

DISABILITIES AND DEFORMITIES OF THE FOOT. 

General Description of the Foot and of its Functions. 

The function of the foot is twofold: to serve as a passive 
support of the weight of the body, and as an active lever to raise 
and propel it. For the proper performance of these functions 
it is constructed to permit elasticity under pressure, and an 
alternation of attitudes under strain, that protect it from injury. 

The Arches.— The most noticeable peculiarity of the foot is 
the arrangement of its arches. As has been suggested by Ellis 
and others, the construction and shape of the arched part of the 




Longitudinal section of the cast of the arch at the point A in Fig. 414. A, the astragalo- 
navicular junction; B, the internal tuberosity of the os calcis; C, the head of the first meta- 
tarsal bone. 

foot may be better understood by considering it as half of the 
arch formed by the two feet. This complete arch may be demon- 
strated by making an imprint of the apposed feet in plaster-of- 
Paris. The plaster cast which represents it will appear in shape 
somewhat like an inverted saucer, the part of each foot that rests 
upon the ground forming half of an irregular ring. If the plaster 
cast is sawed into equal sections it will be seen that the highest 
or thickest part of each division is at the astragalonavicular junc- 
tion; from this point the arch descends sharply to the tuberosities 
of the os calcis, and gradually to the outer border, beneath the 
cuboid bone, and to the metatarsophalangeal joints (Fig. 413). 
A cross-section of the cast will show the contour of what is some- 
times called the transverse arch (Fig. 414), while the section 
through the long diameter will demonstrate the shape of the 



666 



OR TMOPEDIG S UB OEB Y 



longitudinal arch. In descriptions of the longitudinal arch it is 
often divided into two parts, of which the outer division is formed 
by the os calcis, the cuboid, and the two outer metatarsal bones. 
Of this outer arch, the highest point is at the calcaneocuboid 
articulation (Fig. 415), and although it is normally a permanent 
arch, yet the soft tissues are forced downward beneath it when 




Cross-section of the cast of the arches of the apposed feet. A, the internal and inferior 
surface of the astragalonavicular junction. 

weight is borne, so that the outer border of the foot makes an 
imprint throughout its entire length, as contrasted with the inner 
and deeper arch formed by the os calcis, the astragalus, the 
navicular, the cuneiform, and the three inner metatarsal bones 
(Fig. 416). This division, although an artificial one, serves to call 
attention to the fact that the outer or lower arch is more solidly 




The bones of the right foot, viewed from the outer 



(Testut, from Gerrish's Anatomy.) 



braced, and, therefore, better adapted for continuous weight 
bearing than is the higher and more elastic inner arch. 

The diagram of the longitudinal arch, showing its sharp 
descent from the highest point to the centre of the heel, indicates 
that the heel is well adapted for weight bearing, while the long 
anterior pillar composed of several bones is less strong but more 
elastic; thus one instinctively extends the foot in descending 



DISABILITIES AND DEFORMITIES OF THE FOOT 667 

stairs, for example, to avoid the unpleasant jar of direct shock 
received upon the heel. Of this anterior pillar, the third meta- 
tarsal bone is the most direct support, while the more movable 
first and fifth metatarsals, more under muscular control, aid in 
balancing the weight and sustaining it in the different attitudes. 
Both divisions of the longitudinal arch are permanent arches, 
but there are two others which are obliterated under weight — one 
of these is that formed by the heads of the metatarsal bones, the 
anterior metatarsal arch. In the unweighted foot the second and 
third metatarsophalangeal articulations occupy a higher plane 
than their fellows, but when the erect posture is assumed the 
anterior arch is depressed to allow all the metatarsal heads to 
bear their share of the weight. The other arch is formed by the 
internal border of the foot, which curves slightly outward, so that 




The bones of the right foot, viewed from the inner tide. (Testut, from Gerrish's Anatomy.) 

when the two feet are placed side by side an interval remains 
between them, widest at the highest point of the longitudinal 
arch, as is shown in the diagram by the upright section which 
divides the cast of the two soles from one another, the internal 
arch (Fig. 414). When the weight is borne this curved contour 
of the foot becomes straighter, or is obliterated, or is even trans- 
formed to an arch whose convexity is internal (Fig. 434). 

The Foot as a Passive Support.— The foot is supported by 
the muscles, by ligaments, and by the strong plantar fascia that 
covers in the sole. When the foot is actively used it is in great 
part supported by the muscles, but when it serves as a passive 
support, as in standing, the ligaments bear the greater part of 
the strain, and its normal elasticity allows the bearing surface 
to expand as the arches are slightly depressed. If this elasticity 
is diminished, the supports of the arch are subjected to abnor- 



668 OB TH OPE DIC S UR GEJR Y 

mal pressure and the individual may suffer from sensitive corns 
or calloused skin beneath the bones (Fig. 462). Or if the liga- 
ments permit abnormal expansion the arches may become per- 
manently depressed, and, as a result, the range of motion neces- 
sary to the proper functional use of the foot may be permanently 
restricted (Fig. 436). 

When the statement is made that the foot broadens and that the 
arches are slightly depressed under weight, it must not be under- 
stood that the longitudinal arch is simply flattened by direct 
pressure and by elongation of elastic ligaments and fascia. Liga- 
ments and fascia are not elastic in this sense, and they are not, in 
the normal foot, overstretched. The change in contour is the 
effect of normal motion in the joints of the foot, by which it is 
placed in the most favorable attitude for weight bearing without 
muscular exertion — the so-called attitude of rest. 

Of the changes of contour that distinguish the foot used as a 
passive support from the one that bears no weight, the most 
significant is the obliteration of the outward curve of its internal 
border. This change is due to the fact that the astragalus, bear- 
ing the leg, rotates inward and downward on the os calcis until 
it is checked by the resistance of the ligaments and by the inter- 
locking of the bones. The head of the astragalus thus becomes 
slightly prominent, the inner border of the foot is depressed, and 
an attitude is attained in which the weight of the body may be 
supported with but slight muscular exertion. In this attitude of 
rest, as von Meyer has explained, there is general fixation of 
joints of the lower extremity which makes support possible with 
the least muscular exertion. The pelvis tilts slightly backward 
until tension is brought upon the anterior part of the capsule of 
the hip-joint; the femur rotates slightly inward on the tibia, 
which in turn falls slightly inward upon the everted foot. To 
unlock the joints the pelvis must be tilted forward or the hip 
must be flexed. 

The Foot in Activity.— The second function of the foot is as 
a lever to raise and to propel the body. The calf muscles supply 
the power and the heads of the metatarsal bones serve as the 
fulcrum on which the weight is to be lifted. When the foot is 
used as a lever, it should he held in such relation to the leg that 
the line of weight, passing downward through the centre of the 
knee and ankle-joints, is continued over the second toe or prac- 
tically the centre of the foot. As the body is lifted over the ful- 
crum the leg is turned outward in its relation to the forefoot, 



DISABILITIES AND DEFORMITIES OF THE FOOT 669 

because the inner side of the fulcrum, formed by the first meta- 
tarsal bone, is longer than its outer side; thus the strain is directed 
toward the outer and stronger side of the foot (Fig. 417). 

In the proper walk, which is the best illustration of the lever- 
age function, the feet should be held practically parallel to one 
another, so that the line of strain may fall through the centre of 
the foot. As one foot is advanced it first bears weight momen- 
tarily on the heel, then upon its outer border; the heel is then 
raised, and the body is lifted over the toes, the great toe giving 
the final impulse to the step, so that if the walker is looked at 




Illustrating the involuntary adduction The improper attitude of outward rotation, 

of the forefoot, due to the obliquity of in which there is disuse of the leverage func- 

the bearing surface of the metatarsus, tion. 
in the proper attitude for walking. 

from behind he appears to be in-toeing at the termination of 
each step. Thus, during the walk, there is an alternation of 
postures, and the foot, under muscular control, assumes the 
attitudes most opposed to that of passive support. 

Improper Postures. — The alternation of postures and the lever- 
age action of the foot are by no means necessary to simple pro- 
gression; for example, both feet might be fixed in plaster bandages, 
yet walking would be possible, just as it is possible on two wooden 
legs. Indeed, an approximation to such a manner of walking is 
often seen, in which the feet are practically held in the passive 



670 



OB THOPEDIC S UB GEB Y 



attitude, the weight being borne upon the heels. Such a walk 
is necessarily jarring and ungraceful, and if it is not the result 
of weakness and deformity it predisposes to them because of the 
disuse of proper function. 

One means of making the leverage function difficult is the 
custom of turning the feet outward. Outward rotation of the 
limbs is normal in the passive attitude because it increases the base 
of support and thus relieves the muscles. On this very account 
it is the improper attitude for activity because the strain falls 
upon the inner border of the foot, or to the inner side of the ful- 
crum, and makes the proper exercise of muscular power and 

. Fig. 419 Fig. 420 





Voluntary dorsal flexion. Voluntary plantar flexion. 

In these attitudes the astragalus moves with the foot upon the leg bones, as contrasted 

with adduction and abduction, in which the centre of motion is below the astragalus. 

alternation of postures impossible. In other words, the attitude 
normal when the foot is used as a passive support is abnormal 
when it is in active use. 

The Movements of the Foot.— The junction between the foot 
and the leg is made by means of the astragalus, a bone which is 
not intimately connected with either part, since it moves upon 
the leg and upon the foot, and to it no muscles are attached. 

The primary movements of the foot are four in number — dorsal 
flexion, plantar flexion, adduction, abduction. 

Simple dorsal and plantar flexion are confined to the ankle- 
joint, but extreme plantar flexion is combined with slight adduc- 



DISABILITIES AND DEFORMITIES OF THE FOOT 671 

tion, and dorsal flexion with abduction, because the external facet 
of the astragalus allows a greater range of motion on the external 
malleolus than is permitted about the internal malleolus and 
because the forefoot is in plantar flexion turned downward and 
inward on the head of the astragalas and in the reverse direction 
in dorsal flexion. 

The range of motion at the ankle-joint is from 60 to 80 
degrees; thus dorsal flexion to 10 or 20 degrees less than the 





Voluntary adduction. Voluntary abduction. 

In these postures the foot moves upon the astragalus, which is practically fixed between 
the malleoli. Adduction, the turning of the foot inward in its relation to the leg, is always 
accompanied by elevation of its inner and depression of its outer border. This is known 
as supination or inversion of the foot. The reverse of this attitude — pronation or eversion — 
is an accompaniment of abduction, as is illustrated in the figures. 

right angle, and plantar flexion to 50 to 60 degrees more than the 
right angle (Figs. 419 and 420). 

Adduction and abduction of the foot are carried out in the 
mediotarsal and subastragaloid joints. 

Adduction, the motion of turning the foot inward in its relation 
to the leg, is always accompanied by inversion of the sole or 
supination, and by plantar flexion which increases the depth of 



672 



ORTHOPEDIC SURGERY 



the arch because of the shape of the joint surfaces between the 
astragalus and os calcis, where the greater part of the motion 
takes place. Simple adduction and abduction without inversion 
or eversion is possible to a very limited extent in the medio- 
tarsal joint. Its range may be tested by fixing the heel, when 
the forefoot may be moved slightly from side to side upon the 
astragalus and os calcis. The range of motion in the sub- 
astragaloid joint is twice as free as in the mediotarsal joint. The 
character of the motion between the astragalus and os calcis is 
rotation on an axis passing through the upper and inner part of 





The direct dorsal flexors 

Tibialis anterior of right side; outline Peroneus tertius of right side; outline 

and attachment areas. (Gerrish.) and attachment areas. (Gerrish.) 



the head of the astragalus, downward and outward to the outer 
tuberosity of the os calcis. Thus for all practical purposes 
adduction, inversion, and supination are synonymous terms, as 
are abduction, eversion and pronation. 

In the movement of adduction the astragalus is fixed between 
the malleoli, and upon it the os calcis glides forward, its anterior 
extremity turning slightly inward; its inner superior surface is ele- 
vated, and its external surface is depressed. Meanwhile the fore- 
foot, attached to the os calcis, is carried inward and downward 
about the head of the astragalus; its inner border is elevated, and 



DISABILITIES AND DEFORMITIES OF THE FOOT 673 

its outer border is depressed, so that the sole looks inward and 
downward. In this attitude all the arches are increased in depth 
(Fig. 421). _ 

In abduction the bones move upon one another in the reverse 
direction, the curves are lessened, and that of the inner border is 
obliterated (Fig. 422). 

The extreme of adduction is only attained in the position of 
plantar flexion, because in this position the adduction possible at 
the ankle-joint in part, due to the contour of the astragalus and 






The calf muscle. 
Gastrocnemius of right side; outline and 
attachment areas. (Gerrish.) 



The plantar flexor. 
Soleus of right side; outline and attach- 
ment areas. (Gerrish.) 



in part to the greater mobility allowed in the joint when the 
narrow posterior border of the astragalus is alone in contact with 
the malleoli, is added to the adduction which the joints of the foot 
permit. 

Extreme abduction is attained in the attitude of dorsal flexion, 
its extent being about one-half that of adduction; the entire 
range of motion between the two extremes being about 45 
degrees. 

43 



674 



ORTHOPEDIC SURGERY 



In this description the foot is considered as moving on the 
leg, but in the attitude of rest the foot becomes the fixed point 
and the astragalus moves upon the os calcis in the manner and to 
the position already mentioned in the description of abduction — 
i. e., it slips downward and forward and turns inward; at the 
same time the anterior extremity of the os calcis turns slightly 
inward and downward, and its inner border is depressed. Corre- 
sponding to this movement, as the inner border of the foot be- 
comes straight or bulges inward, the navicular is forced forward 
and downward and the longitudinal arch is depressed. As has 

Ftg. 427 Fig. 428 





The direct abductors. 



Peroneus longus of right side; outline 
and attachment areas. (Gerrish.) 



Peroneus brevis of right side; outline and 
attachment areas. (Gerrish.) 



been mentioned, the turning of the leg inward and the correspond- 
ing-turning of the foot outward in its relation to it locks in a 
manner the ankle-joint, and at the same time throws the strain 
upon the ligaments, so that standing in the erect posture is possible 
with but little muscular exertion (Fig. 434). 

To put it in a simpler manner, the leg supporting the weight 
of the body has a tendency to tilt the foot over toward the inner 
side and to evert the sole; thus, under increasing superincumbent 
weight, the point of greatest pressure on the sole shifts from its 
centre and outer border toward the inner border. If, on the 
other hand, the body is raised upon the toes, the arch is relieved 



DISABILITIES AND DEFORMITIES OF THE FOOT 675 



from strain and the weight falls upon the front and outer part of the 
foot. Plantar flexion and adduction represent, as contrasted with 
the passive attitude of supporting weight, the attitude of activity 
in which the foot is supported and controlled by the muscles. 

The Function of the Muscles.— The most important function 
of the dorsal flexors is to lift the foot as it is swung forward; of 
the plantar flexors to serve in the active propul- 
sion of the body. The difference in function is 
shown by the relative strength of the two groups, 
the plantar flexors being five times the stronger; 
in fact, the calf muscle (gastrocnemius and soleus) 
alone is three times as strong as all the other 
muscles of the foot combined. It is practically 
the leverage muscle, the others serving more es- 
pecially to fix and to hold the forefoot or fulcrum 
in its proper relation to the leg. It is also a 
powerful adductor and supinator of the foot 
in the attitude of plantar flexion (Figs. 425 and 
426). 

The muscles that more directly support the 
inner arch of the foot are the tibialis posticus and 
tibialis anticus, whose tendons approach to their 
attachments in front of the astragalus. The 
tibialis anticus supports the internal border of the 
foot from above, and is the direct supinator of 
the foot in dorsal flexion— that is, if unopposed 
it elevates the inner border of the foot, when it 
acts as adorsiflexor. The tibialis posticus is the 
most powerful adductor (Figs. 423 and 429). The 
extensor longus hallucis is an adjunct of the tibialis 
anticus in its action on the foot as a whole. The 
extensor longus digitorum, including the peroneus 
tertius, is a dorsal flexor and abductor. 

The flexor longus hallucis, passing directly 
beneath the sustentaculum tali, aids in supporting 
the weak part of the foot and its position demonstrates the im- 
portance of the proper functional use of the great toe (Fig. 433). 

The peroneus longus and brevis support the outer arch, and 
the former binds the foot together and holds the great toe firmly 
against the ground; thus it indirectly supports the longitudinal 
arch against direct pressure (Figs. 427 and 428). They also serve 
as abductors and pronators. 



The most impor- 
tant adductor. Tibi- 
alis posterior of right 
side; outline and at- 
tachment areas. The 
most of the muscle 
is represented as if 
seen through the 
bones. (Gerrish.) 



676 OB THOPEDIC S UB GEB T 

The relative strength of the muscles and their functions is 
indicated in the following tables i 1 

Dorsal Flexors of the Foot; Strength Reckoned in TCilo- 
grammetres. 

Tibialis anticus 0.871 

Extensor longus digitorum 0.280 

Extensor longus pollicis 0.155 

Peroneus tertius 0.087 

1.393 
Plantar Flexors. 

The calf c Soleus 3.256 

muscle, t Gastrocnemius 2.831 

Flexor longus pollicis 0.218 

Peroneus longus 0.118 

Tibialis posticus 094 

Flexor longus digitorum 0.078 

Peroneus brevis .' 0.055 

6.650 

The Foot Considered as a Mechanism. —In the study of the 
deformities, and particularly of the functional weaknesses of the 

Fig. 430 Fig. 431 





Extensor proprius hallucis of right side; 
ltline and attachment areas. (Gerrish.) 



Extensor longus digitorum of right side; 
outline and attachment areas. (Gerrish.) 



foot, one must never lose sight of the fact that it is a mechanism, 
subject to mechanical laws, and that its deformities and disa- 
bilities, its relative strength or weakness, can be appreciated only 
by comparing it with the normal standard. Marked deformity or 



Ueber die Arbeitsleistung der auf die Fussgelenke Wirkenden Muskeln, R. Fick, Leipzig . 



DISABILITIES AND DEFORMITIES OF THE FOOT 677 

distortion is evident at a glance, even though the apparatus is not 
in use, but functional ability can be judged only by the manner 
in which active work is performed. 

As has been stated, the foot is, in activity, a lever, by means 
of which the weight of the body is lifted and propelled. If it is 
loosely constructed or insufficiently supported by the ligaments, 
it cannot be properly controlled by the muscles. If, on the other 
hand, the muscular power is insufficient, the weight of the body 

Fig. 432 . Fig. 433 



% 



Flexor longus digitorum of right side; 
outline and attachment areas. The muscle 
is represented as seen from in front 
through the bones. (Gerrish.) 



Flexor^longus hallucis of right side; 
outline and attachment areas. The 
muscle is represented as seen from the 
front through the bones. (Gerrish.) 



cannot be lifted and properly balanced upon it. The structure 
of the foot may be normal, and its muscles may be of normal 
strength, yet the strain placed upon it may be disproportionately 
great. The strain may be overweight of body, or the overwork of 
a laborious occupation, but more often the machine is overworked 
because it is weakened by compression and consequent distortions 
and because it is subjected to mechanical disadvantages in the 
performance of its functions, by the assumption of improper 
attitudes. 



678 



ORTHOPEDIC SURGERY 



One of the most common of such attitudes is, as has been 
mentioned, that of turning the feet outward in walking; for as 
the fulcrum is displaced outward, the strain falls through the 
inner and weaker side of the foot. As a consequence of the 
improper attitude there is usually, to a greater or less degree, 
disuse of the active leverage function, the foot being used some- 
what as if it were a movable pedestal. (Fig. 418). This posture 




An attitude that simulates the flat-foot. 
(See Fig. 435.) 



Fig. 435 compared with Fig. 443 
illustrates the voluntary protection of 
the foot from overstrain. 



often induces or is associated with abduction of the foot, the passive 
attitude that predisposes to pain and weakness. 

This disuse of the active function may be unnecessary, just as 
the outward rotation of the feet with which it is associated is a 
habit, a habit that is often the result of improper teaching. On 
the other hand, the habitual assumption of the passive attitude 
may be induced by injury or disease of the foot, or by corns or 
bunions, or by improper shoes. For under such conditions the 
strain of the leverage function increases the discomfort; conse- 
quently it is discontinued. It must not be inferred that such 



DISABILITIES AND DEFORMITIES OF THE FOOT 679 

improper attitudes lead directly to weakness and discomfort, 
for in most instances an ungraceful carriage and gait are the only- 
ill effects. The improper attitudes must, however, lessen the 
power and resistance of the foot, and they must be reckoned, 
therefore, among the important predisposing causes of disability. 
The passive attitude, it will be remembered, is the attitude 
of rest, in which the ligaments bear the greater part of the strain 
and in which the arches of the foot are depressed or obliterated. 

The Weak Foot. 

Synonyms. — Splay-foot, flat-foot. 

The introductory pages lead naturally to the consideration of 
the most important of the acquired disabilities of the foot, a 
disability whose most important 
characteristic in the mildest and FlG ' 436 

in the most advanced type is the 
'persistence of the passive attitude 
of abduction, or an approxima- 
tion to it, in place of normal 
alternation of posture. Disuse 
of function is followed by restric- 
tion of motion, particularly in the 
range of adduction and plantar 
flexion, and finally by persistent 
deformity, a deformity which is 
simply an exaggeration of the 

normal posture assumed when Typical "flat-foot" of moderate degree, 

, « ~ • . , ,-p,. illustrating the component elements of ab- 

the IOOt Supports Weight (Jblg. duction and depression of the arch. 

434). This is the so-called flat- 
foot (Fig. 436). At first glance it may seem that the depression of 
the arch is the most noticeable peculiarity in a characteristic case of 
flat-foot, and that the popular name is, therefore, an appropriate 
one. On closer examination, however, it will appear that the foot 
is not flat because its " keystone has sunk," but that the lowered 
arch is caused by lateral displacement (abduction) . This fact may 
be demonstrated by adducting the foot sufficiently to restore ap- 
proximately the normal relation between it and the leg, a movement 
which will restore its normal contour. 

The deformity then may be analyzed as follows: 
1. The leg is displaced inward, so that the weight falls upon 
the inner side of the foot. 2. The leg is rotated inward so 
that a line drawn through its centre, prolonged from the crest 




680 



ORTHOPEDIC SURGERY 



of the tibia, instead of falling over the second toe, now points 
inside the great toe, or even over the centre of the internal border 
of the foot (Figs. 436 and 439). 

It has been stated that under normal conditions, in the act of 
passive weight bearing, the astragalus rotates downward and 
inward upon the os calcis, depressing its anterior and internal 
border until the movement is checked by the strong ligaments 
connecting the bones, the calcaneonavicular, the deltoid, and the 
interosseus; in other words, in the passive attitude the leg has a 
tendency to slip downward and inward from off the foot. In the 
weak foot this inclination has become an accomplished fact, for the 
normal movement has become so exaggerated by the distention of 
the ligaments and by the weakness of the supporting muscles that 
an actual subluxation is present. The astragalus has rotated and 
slipped far to the inner side of its normal position, to an attitude 





The relation of the astragalus to the 
os calcis. 



The relation of the astragalus and 
calcis in flat-foot. 



of exaggerated rotation and plantar flexion, so that its head can 
be plainly felt on the internal border of the foot. The anterior 
extremity of the os calcis is depressed and is turned slightly in- 
ward and its internal border is lowered (Fig. 438). 

The navicular bone has been depressed with the head of the 
astragalus, although to a less degree, it has been forced farther 
away from the os calcis, and the entire inner border of the foot 
is lowered. Thus the depression of the arch is always accom- 
panied and preceded by a bulging inward of the inner side of the 
foot. 

The typical flat-foot is, as it were, broken in the centre (Fig. 
436), the posterior division having turned inward and downward, 
while the forefoot is forced downward and outward. The dislo- 
cation may be so extreme that the entire sole of the foot rests 
upon the ground, and a callus even may be found at the point 



DISABILITIES AND DEFORMITIES OF THE FOOT 



that usually represents the highest point of the arch, which now 
supports the greatest burden. 

In this change of relation between the bones the arched part 
of the foot or waist appears much broader than normal, even 
broader than the front of the foot; the heel projects, the external 
malleolus is depressed and carried forward by the rotation of 
the leg, and is much less prominent than normal; the internal 




it, showing the inward rotation 
of the legs when the abducted feet are 
placed side by side, indicating an attitude 
of persistent abduction. 



Weak feet, arches not depressed. 



malleolus is more prominent, and with the astragalus it overhangs 
the bearing surface of the sole. The entire mechanism is out of 
gear; its motion is, therefore, very much restricted. It is mani- 
festly impossible for the patient to adduct the forefoot— that 
is, to turn it inward about the head of the displaced astragalus. 
Plantar flexion is also much limited, because of the persistent 
adduction and plantar flexion of the astragalus. Dorsal flexion, 
on the other hand, although it is actually restricted, may appear to 



682 ORTHOPEDIC SURGERY 

be abnormally free, because the forefoot is abducted and slightly 
dorsiflexed upon the head of the astragalus (Fig. 436). 

The disability and its accompanying deformity are found in 
every grade of severity. Discomfort usually begins when the strain 
upon the muscles is disproportionate to their strength, and it 
is increased when the ligaments begin to give way under strain, 
allowing the bones to occupy an abnormal relation to one another. 
It is evident, therefore, that the individual in whose foot the arch 
is well-formed and whose ligaments are firm, will suffer from the 
symptoms of strain long before the arch has been depressed; 
also, that the lateral inward bulging, characteristic of abduction, 
must be very great before the arch is completely flattened. In 
this type the prominent deformity is lateral displacement (valgus). 
On the other hand, if the individual has inherited a low arch, 
or if, as the result of weakness in early life, the arch has been 
depressed or has never formed, accommodative changes in the 
bones will have taken place during growth, so that the flat-foot 
of this type will not be attended with as much change in its rela- 
tion to the leg, and, therefore, disturbance of function, as in the 
typical case that has been described. This latter class of cases 
exemplifies the popular type of flat-foot that may exist without 
pain or disability, and in which the most noticeable peculiarity is 
the obliteration of the arch (planus). (Contrast Figs. 440 and 442.) 

In certain instances abnormal laxity of ligaments allows de- 
formity of the valgus type when weight is borne, yet the foot, 
controlled by efficient muscles, may be apparently normal in func- 
tional ability, while in other cases in which the ligaments are nor- 
mal and yet are subjected by insufficient muscular protection to 
overstrain, disability and pain may precede noticeable deformity. 

It is evident that the lowering of the arch is of secondary im- 
portance in the deformity, and that the popular significance of 
painful flat-foot, as an inherited and irremediable weakness, is 
most misleading. Yet it seems to have governed the treatment 
of the disability until very recently. On the one hand, the early 
cases were overlooked because the foot was not flat, while those 
in which the deformity was more advanced were either neglected 
or were treated by simple supports beneath the arch or by opera- 
tion without regard to the loss of function, and, therefore, without 
hope of ultimate cure. 

As has been stated, there is one feature common to every grade 
of the so-called flat-foot: the foot regarded as a machine is weak 
as compared to the normal standard — weak because of the per- 



DISABILITIES AND DEFORMITIES OF THE FOOT 683 

sistence of the attitude of rest and relaxation, as contrasted with 
that of activity and strength, and weak because the proper rela- 
tion between the power and the fulcrum is changed. Even 
the inherited flat-foot or the flat-foot which has never caused 
symptoms is weak in the sense that, in use, it lacks the spring 
and elasticity characteristic of the perfect machine. The term 
weak foot may be used, then, to include all types of the disability. 

In one weak foot the arch has disappeared (Fig. 436); in 
another weak foot the arch is of normal depth, but the foot is 
habitually abducted (Fig. 440). In one case the deformity 
appears only under weight; in another the foot is held rigidly 
in the deformed position by muscular spasm. In one instance 
there may be great deformity without pain; and in another dis- 
abling weakness and pain without noticeable deformity. In one 
case the foot is unable to perform its functions because of its 
inherent weakness; in another the disability may be due simply 
to the improper use of a normal structure. 

Pathology. — Supposing the foot to have been normal before it 
began to break down, it is evident that persistent deformity could 
not have been acquired without marked changes in its internal 
structure. In a general way these changes have been indicated 
already. The ligaments on the internal aspect of the foot and of 
the ankle-joint are weak and distended; the unused portions of the 
articular surfaces of the joints may be denuded of cartilage, while 
new facets may have formed to accommodate the changed rela- 
tions of the bones. For example, the external malleolus may be 
in direct contact with the os calcis; evidences of injury and of 
abnormal pressure may be found in the thickened periosteum, 
in formation of osteophytes, while the internal structure of the 
bones has been changed in adaptation to the new conditions. The 
disused muscles, particularly the plantar flexors and adductors, 
have become atrophied, as evidenced by the shrunken calf. The 
muscles on the inner border of the foot have been overstretched, 
while those on the upper and outer part have become shortened 
and contracted in accommodation to the habitual posture. Such 
a foot represents an extreme, it may be an irremediable degree 
of deformity; but in by far the greater proportion of the cases 
the pathological changes have not advanced to a stage that 
precludes successful treatment. 

Etiology. — In all cases the actual symptoms of pain and dis- 
ability are due to a disproportion between the burden or strain 
and the ability of the machine to perform it. 



684 ORTHOPEDIC SURGERY 

This theory accounts for the fact that the weak foot, although 
very common in childhood, does not, as a rule, cause troublesome 
symptoms until adolescence, when the weight and strain put upon 
it are increased. It explains why the foot, which may be fairly 
normal in structure, breaks down often in later adolescence or 
early adult life when the continuous strain of regular occupation 
is undertaken. It is evident, also, that an occupation that in- 
duces a persistence of the passive attitude, that of waiters, cooks, 
and bartenders, for example, exposes the feet to greater strain 
than one which encourages alternation of postures. And that 
the symptoms are likely to be more severe and the deformity to 
be greater among those who are obliged to labor than among 
those who are not. Overwork or strain, of occupation or other- 
wise, may be temporarily disproportionate because of general 
weakness, as, for example, during pregnancy or after recovery 
from exhausting disease; or because of local injury or disease of 
the foot itself, which weakens it directly or indirectly by inducing 
improper attitudes. This theory explains why there is no con- 
stant relation between the degree of deformity and the severity of 
the symptoms, for, although all weak feet are mechanically weak, 
yet all weak feet are not necessarily painful feet. Pain is not 
caused because the foot is flat; it is a symptom of strain and 
injury and of progressive deformity. The progress of the de- 
formity may be temporarily or permanently checked at any stage, 
either by removal of the exciting causes or because of the resist- 
ance of the tissues; then the pain intermits or ceases. 

This conception of the foot as a mechanism, of which grades 
of efficiency may be recognized, has a great advantage, since it 
enables one to perceive wherein a foot is weak, even though the 
weakness causes no symptoms whatever, and thus to prevent 
discomfort and deformity by the recognition and treatment of ito 
predisposing causes. 

Statistics. — A brief analysis of 1000 cases of so-called flat-foot 
treated at the Hospital for Ruptured and Crippled will represent 
fairly the points of general interest in this class of cases : 

The Age and Sex op the Patients. 

Age. Males. Females. Total. 

Ten years or less 68 30 98 

Ten to fifteen 112 87 199 

Fifteen to twenty 144 83 227 

Twenty to twenty-five 94 53 147 

Twenty-five to thirty 68 41 109 

More than thirty 132 88 220 

618 382 1000 

Foot affected: right, 133; left, 138; both, 729. 



DISABILITIES AND DEFORMITIES OF THE FOOT 685 

In 58 cases the cause of the disability appeared to be injury, 
and in 65 instances it was, apparently, due to rheumatism or to 
rheumatoid arthritis. The symptoms usually appear first in one 
foot, and, as a rule, they are at all times more marked on one 
side. Of 569 instances, in which the duration of symptoms was 
recorded, it was six months or less in 409. 

The age of the patients is of interest as bearing on the question 
of prognosis: 426 were between ten and twenty years of age, and 
780 were less than thirty. 

Hospital statistics cannot adequately represent the subject, for, 
as a rule, it is because of disability and pain that these patients 
apply for treatment. In the larger proportion of the cases recorded 
muscular spasm and rigidity were present, in 234 instances to 
such a degree that forcible overcorrection was advised — an opera- 
tion rarely necessary in private practice. 

It is in childhood that the prevention of subsequent weakness 
and deformity is of the first importance, yet but 98 children of 
ten years of age or less are recorded, and many of these were 
brought, not for weakness or deformity, but for treatment of the 
symptomatic in-toeing. 

Symptoms. — As has been stated, the symptoms of the weak 
foot, although similar in type, vary in severity according to the 
local condition and the disturbance of function, the work to be 
performed, and the susceptibility of the individual. The earliest 
symptom is usually a sensation of weakness; the patient begins 
to recognize as familiar a feeling of discomfort, of tire and strain 
about the inner side of the foot and ankle; sometimes after long 
standing a dull ache in the calf of the leg or pain at the knee, 
hip, or in the lumbar region, symptoms more common in women 
than in men; or after overexertion a momentary sharp pain radi- 
ating from the point of weakness; thus the patient often dates the 
history of his trouble from a long walk or other form of over- 
work. After a time the patient may become aware that he is accom- 
modating his habits to his feet; he rides when he once walked; he 
sits when he once stood; he no longer runs up or down stairs or 
springs off the street-car. His feet have lost their spring, as he 
expresses it, which means that the foot is no longer supported and 
controlled by muscular activity and is no longer used as a lever. 
Not infrequently early symptoms are pain and sensitiveness at the 
centre of the heel, explained in part by the jarring heel walk which 
is always assumed when the foot is weak, and in part by the strain 
upon the attachments of the deep plantar ligaments. The patient 



686 ORTHOPEDIC SURGERY 

may complain that he cannot buy comfortable shoes; the reason 
is that the weak foot under use is changed in shape, so that the 
shoe that was comfortable in the morning compresses the foot 
painfully at night; thus increasing discomfort from corns, bunions, 
enlarged great toe-joints, and deformities of the toes is experienced. 
Coldness and numbness, congestion and increased perspiration, 
caused by the impaired circulation and weakness, are common 
symptoms in this class of cases. Actual pain is, as a rule, felt 
only when the foot is in use; it ceases under temporary rest or 
relief from disproportionate work, and it is this remittance of 
symptoms, together with the fact that the discomfort is usually 
more marked in damp weather, that leads so often to the mistaken 
diagnosis of rheumatism. The foot is weak and vulnerable; the 
patient now recognizes that he has what he speaks of as a 
weak ankle, or sprain, or gout, or rheumatism, but if he has 
accommodated himself to the weakness but little discomfort is 
experienced. In many instances such relief or accommodation is 
impossible, and it is, therefore, among the working class that one 
oftener sees the frank and rapid development of the disability 
and deformity. The range of motion becomes more and more 
restricted; the habitual attitude, at first exaggerated to deformity 
only under the influence of the weight of the body, remains as a 
permanent displacement of the bones. The weak and dislocated 
foot is subjected to constant injury, to what may be likened to a 
succession of slight sprains, so that local congestion, sensitiveness, 
arid swelling may appear, together with muscular spasm, rigidity, 
and pain on passive motion. Because of this stiffness of the foot, 
which has lost the power to accommodate itself to inequalities of 
the surface, the patient dreads to cross a rough pavement, for 
every misstep is a source of pain. Another symptom, the dis- 
comfort felt in changing from a position of rest to activity, which 
is usually present in slight degree at every stage, now becomes 
more prominent. The patient, after sitting or on rising in the 
morning, is unable to walk, but staggers or limps for several 
minutes, a symptom explained by the fact that when the foot is 
at rest there is a partial reposition of the displaced bones, which 
must again be forced into the deformed posture that has become 
habitual. The local sensitiveness and muscular spasm are increased 
by use, so that the patient may have difficulty in removing the 
shoe at night, and the symptoms relieved by the rest of Sunday 
become progressively worse during the week. The pain and 
discomfort are more general in character, and are often referred 



DISABILITIES AND DEFORMITIES OF THE FOOT 687 

to the dorsum of the foot, representing muscular rigidity and 
tension, and to the ankle where the external malleolus is grinding 
out a facet in the projecting os calcis. The patient may now 
complain of discomfort in the feet and cramps in the legs, even 
when in bed, and the weakness, awkwardness, and even mental 
depression may be so noticeable that the case is sometimes 
mistaken for serious disease of the nervous system. 

The appearance of such a foot has already been described, and 
the effect of the deformity on its functions should be evident. 
The gait is slouchy and cloddy, what has been spoken of as the 
pedestal walk; the feet are simply pushed by one another, in 
the attitude of eversion, the knees are slightly flexed, and the 
weight is borne entirely upon the posterior segment of the foot. 
The muscles have atrophied, the foot is cold and congested from 
its continued inactivity, and it is usually bathed in perspiration. 
A certain range of motion remains at the ankle-joint, but adduc- 
tion is absolutely restricted by the shortened and spasmodically 
contracted muscles on the outer and upper surface. This type 
represents, of course, only the severe variety that is more likely 
to be seen in hospital than in private practice; and it would seem, 
were it not for the evidence to the contrary which the histories 
of the patients present, that the nature of the trouble must be 
recognized at a glance. But in the milder and earlier cases the 
diagnosis is not always so easily made. 

Diagnosis. — In all cases of suspected weakness of the foot a 
thorough and orderly examination should be made, not only of 
its appearance, but also of its functional ability. Such an exami- 
nation is not merely for the purpose of diagnosis, which is usually 
apparent, but in order that the degree and character of the 
temporary or permanent changes in structure and function may 
be properly estimated. 

Attitudes. — One begins the examination by noting the manner 
of standing and walking. The heel walk, the exaggerated turning 
out of the feet, the slouchy gait in which the leg is never com- 
pletely extended, in which the power of the calf muscle is not 
applied, and in which the essential postures of the foot are disused, 
are all elements of weakness that should be corrected whether 
they cause symptoms or not. 

Distribution of Weight and Strain. — The distribution of the 
weight of the body and the habitual use of the foot are often 
made evident by examining the worn shoe. If it is bulged inward 
at the arch or worn away on the inner side of the sole it shows 



688 



ORTHOPEDIC SURGERY 



weakness (Fig. 445). The same observations are then made on 
the bare feet, particular attention being paid to the line of strain 
or leverage; thus a line drawn down the crest of the tibia from 
the centre of the patella, continued over the foot, should meet the 
interval between the second and third toes; if it falls over or 
inside the great toe, it shows that the foot is working at a dis- 
advantage (Fig. 439). 

Contour. — The contour of the foot should then be examined; 
its internal border should curve slightly outward, so that if the 




The ordinary type of weak foot in a child. The attitude of abduction causes the 
apparent fiat -foot. (See Fig. 442.) 

feet are placed side by side with the toes and heels in apposition 
a slight interval remains between them; if this slight concavity is 
replaced by a noticeable convexity when weight is borne the foot 
is weak (Fig. 440). This change in contour is the earliest and 
sometimes the only evidence of deformity. The arch of the 
foot properly protected by the muscles and by a proper attitude, 
sinks but little under weight; there is a slight elasticity only, 
as the strain is thrown more to the inner side of the median line,, 
and if the deoression is^marked it shows weakness. 



DISABILITIES AND DEFORMITIES OF THE FOOT 689 

Bearing Surface. — The exact amount of bearing surface may be 
shown by an imprint upon carbon paper or by smearing the sole 
with vaseline; then, as the patient stands upon a sheet of white 
paper, the outline of the foot should be traced so that the relative 
size of the imprint to that of the foot may be shown and compared 
with the normal standard (Fig. 447). 

Or the patient may stand upon a square of plate glass fixed in 
a table and the bearing surface may be examined under different 




Voluntary correction of the deformity, illustrating particularly the restoration of the 
arch. (See Fig. 441.) 

degrees of pressure and in different attitudes as suggested by 
Lovett. 

The Range of Motion. — The balance of the foot, as shown by 
the range of motion, is next to be tested, for its limitation is one 
of the earliest signs of improper attitudes and of weakness. This 
range of motion varies somewhat within normal limits; it is usually 
greater in childhood than in adult life, greater in the slender 
than in the massive foot, and greater in the foot used properly 
than in one that is not. The first test is applied to simple dorsal 
and plantar flexion; the leg must be fully extended at the knee; 

44 



690 ORTHOPEDIC SURGERY 

the line of strain must be in its normal relation, so that the foot 
may be neither adducted nor abducted, and the observation must 
be made on its outer border. 

In this position the patient should be able to flex the foot from 
10 to 20 degrees less than the right angle, and to extend it from 
40 to 50 degrees beyond the right angle, the range of motion 
being from 50 to 60 degrees (Figs. 419 and 420). 

By far the most important test is that of the power of adduc- 
tion or inversion of the foot, the test of the mediotarsal and sub- 
astragaloid joints, a motion in which the os calcis is drawn for- 
ward and inward under the astragalus, while the forefoot is flexed 
about its head. With the leg extended and the patella in the median 
line the foot is turned inward as far as possible; the elevation 
of its inner border or supination and the turning in of the heel 
are well illustrated in Fig. 421; the actual range of adduction 
is somewhat difficult to measure, but it is about 30 degrees. 
Even the mild and early cases of weak foot usually show some 
limitation of this most important motion, and in many instances 
it is completely lost, the patient turning the entire limb in the effort 
to adduct the foot. The less important motion of abduction 
may be tested also (Fig. 422) ; its range is about half that of adduc- 
tion, so, also, the range of supination or inversion of the sole 
is nearly twice as great as that of pronation or eversion of the 
sole. In other words, the internal border of the foot can be raised 
twice as far from the floor as can the external border. The range 
of passive motion is then tested by pushing the foot in all directions. 
The range of dorsal flexion is from five to ten degrees beyond that 
of voluntary motion, while passive extension, so far as it applies 
to the ankle-joint, is about the same as the voluntary, although 
the forefoot may be still farther bent downward at the mediotarsal 
joint. The limit of passive adduction is considerably beyond 
that of voluntary inversion. 1 

Passive motion serves several purposes; contrasted with the 
range of voluntary motion it shows the habitual use of the foot, 
since the motion least used is most limited. It also makes evi- 
dent the slight restriction of motion and the presence of local sensi- 
tiveness, which, even in early cases, are usually present. Thus, 

1 As adduction and inversion and abduction and eversion are always combined, one 
term is used to signify the movement inward or outward; thus, inversion means adduction; 
abduction implies eversion. A fixed attitude of adduction and inversion is called varus; a 
fixed attitude of abduction and eversion is called valgus. Varus and valgus signify, there- 
fore, deformity. Thus the term valgus, although it may be properly applied to designate 
the deformity of weak foot, is usually reserved for the more extreme and persistent 
distortion of talipes. 



DISABILITIES AND DEFORMITIES OF THE FOOT 691 

if pressure is made just in front of and below the internal malle- 
olus, at the astragalonavicular junction, and if at the same time 
the foot is forcibly adducted, the patient will complain of pain 
at the point of pressure and of a feeling of constriction and 
tension about the dorsum of the foot before the normal limit of 
motion is reached. When the foot is dorsiflexed the plantar 
fascia is put upon the stretch, and its condition may be noted, 
for a contracted and sensitive plantar fascia may cause sufficient 
discomfort to induce improper attitudes and thus it may predispose 
to further disability. 

Varieties. — This mode of examination will demonstrate the 
disability, and the secondary changes in the mechanism, which 
must be overcome before a cure can be accomplished. By it one 
will learn to recognize several grades of weak foot: 

1. The normal foot improperly used, as shown by the manner 
of standing and walking (Fig. 418). 

2. The foot which because of laxity of ligaments or insufficient 
muscular support is forced by the weight of the body into an 
attitude of deformity; that s, in which the foot under weight 
falls into an abnormal attitude of abduction in its relation to the 
leg as evidence:! by the inward projection of its inner border and 
by the overhanging internal malleolus. As a rule, there is sufficient 
laxity of ligaments to allow a depression of the arch, as shown by 
the imprint, but in other instances, although the arch seems lower 
because of the characteristic attitude of abduction, in which the 
leg, as it were, overhangs the foot, yet the imprint shows that 
there is no increase in the area of bearing surface. Indeed, if 
the eversion is sufficient to raise the outer border of the foot, this 
may be even smaller than normal; thus, an individual may suffer 
from so-called flat-foot whose arch is actually exaggerated (Fig. 
440). 

3. The weak foot, which shows typical deformity under use 
and in which the range of voluntary motion is somewhat limited, 
particularly in the direction of plantar flexion and adduction. 
Forced motion causes discomfort and pain, indicating certain 
accommodative changes in structure, which are not apparent 
when the foot is not in use (Fig. 436). 

4. The foot which presents typical and persistent deformity, 
whether it is in use or not, and in which the range of both volun- 
tary and passive motion is much restricted. In all of these varieties 
the improper functional use of the foot, particularly the loss of 
active leverage, is very evident when the patient walks (Fig. 445). 



692 ORTHOPEDIC SURGERY 

Limitation of Motion and Muscular Spasm. — Limitation of motion 
is caused by the changes in structure in accommodation to 
functional use. These are first evident in the muscles and liga- 
ments, and, finally, in the articular surfaces of the bones. Added 
to this underlying limitation of motion there is usually a certain 
degree of muscular spasm, which varies in grade with the local 
congestion, irritation, and inflammation of the joints and tissues. 
In the quiescent flat-foot it may be absent, but on renewed injury 
or overwork of the weak structure it again appears. It depends 
also upon the irritable condition of the overworked and contracted 
abductor muscles, practically the only group which retains func- 
tional power; thus the spasm, as has been stated in describing 
the severe and painful type of weak foot, is greater after the day's 
use and relaxes somewhat during the night. The degree of 
muscular spasm and rigidity corresponds with the intensity of the 
symptoms, but by no means with the depression of the arch or 
with the duration of the deformity. 

Extreme Types of Weak Foot. 1. Persistent Abduction. — In 
one type of deformity the foot is twisted outward and upward. 
It may be everted to such an extent that practically the weight 
is borne upon the heel and the ball of the great toe. In such 
instances the astragalus, although rotated inward upon the 
pronated os calcis, is, of course, not plantar flexed nor is the 
anterior extremity of the os calcis depressed. The entire foot is 
simply held in an attitude of extreme abduction and dorsal flexion 
by the spasm and contraction of the flexors and abductors, so that 
the leg must be bent at the knee and inclined forward to bring 
the sole to the ground. Such extreme cases are uncommon. 
They are often the direct result of injury, so-called chronic sprain. 
Less extreme examples of this class are very common. The foot 
is simply turned to one side (valgus) and the arch appears to be 
depressed because of the attitude, whereas it may be in reality 
exaggerated in depth. 

2. Pes Planus. — As has been stated already, and as is well- 
known, there is a type of painless flat-foot sometimes called pes 
planus, in which the flatness of the foot is more noticeable than 
the other components of the deformity that have been described. 
This is probably the result of inherited laxity of ligaments or of 
rhachitis or other form of acquired weakness in early life, so that 
a normal arch was never present. Such a foot controlled by 
normal muscles may be strong and efficient, but it is, nevertheless 
deformed, and it is doubtful if its possessor ever could attain the 



DISABILITIES AND DEFORMITIES OF THE FOOT 693 

grace and elasticity of gait possible under normal conditions. It 
is said, also, that a low arch is normal in certain races, for example, 
the negro, but the American negro is certainly not exempt from 
the pain and disability incidental to the broken-down foot. 

It is evident, of course, that the breaking down of a properly 
shaped foot, supported by normal ligaments, will be attended 
by greater pain and greater disability than of one in which the 
arch was originally low and of which the ligaments were weak, 
because it is during the progression of the deformity and particu- 
larly in its early stages that such symptoms are most prominent. 




Weak feet and slight knock-knee 



When the bones of the arch rest upon the ground or when final 
stability has become assured, pain may cease, and permanent 
accommodation to the new conditions may increase the ability of 
the deformed member. Such an outcome might be quickly 
accomplished in the foot originally flat, while in the other instance 
the symptoms, although remitting from time to time, might con- 
tinue indefinitely. 

The abducted foot, in which there is no depression of the arch, 
and the simple flat-foot, in which the element of abduction is less 
prominent, represent the two extremes of weak foot. In the 
majority of cases the two are combined in varying degree. 



694 OR THOPEDIC S UB GEB Y 

One may recognize, then, three types of weak foot which may be 
classified according to the more noticeable deformity as 

1. Valgus, or abduction. 

2. Valgo-planus, or abduction and depression. 

3. Plano-valgus, or depression and abduction. 

This distinction is of some importance from the standpoint of 
prognosis, at least in the adolescent and adult cases, as the pros- 
pect of anatomical cure corresponds to the order of classification. 

Weak Foot in Childhood. 

There can be no doubt that in many instances the origin of the 
weak foot may be traced to early childhood. Certainly, deform- 
ities and improper attitudes are very common at this period, and 
it is much more likely that they are ingrown than outgrown. 
Actual pain from the weak foot is unusual at this age. The child 
may complain of fatigue and may be weak and awkward, but 
it is usually because of the very evident deformity rather than 
because of symptoms that advice is asked. In these cases, as in 
every case, the habitual attitudes and use of the feet are of the 
first importance. 

Out-toeing and In-toeing as Symptoms of the Weak Foot in 
Childhood. — One of the most frequent of the improper postures 
is that of exaggerated outward rotation of the feet, which is not 
only an ungraceful attitude, but a direct cause of weakness as well. 
The opposite attitude of inward rotation, the so-called "pigeon- 
toed" walk, is most offensive to relatives and friends, and it is 
for correction of the attitude that the child may be brought for 
treatment. The attitude is, in many instances, a sign of the weak 
foot, for on examination the bulging on the inner side, the inward 
rotation of the leg in its relation to the foot, and the depressed 
arch show very plainly that it is the foot and not the attitude 
that requires treatment; in fact, the attitude is, in this class of 
cases, really a safeguard against increasing deformity, which will 
correct itself when its cause is removed. 1 Particular emphasis is 
laid upon this point, which is very generally overlooked, because 
the routine treatment of the "pigeon-toes" in these cases might 
be the cause of direct harm. 

Weak Ankles. — "Weak ankle" is a term popularly applied 
to the weak foot of childhood, in which the foot is in a position 

1 Inward rotation of the limb, an attitude controlled by the muscles at the hip, and 
inversion of the foot are usually confounded. Inward rotation of the limb (pigeon-toe) 
and eversion of the foot (weak foot) are often combined in childhood. 



DISABILITIES AND DEFORMITIES OF THE FOOT 695 

of valgus when in use, so that the sole of the shoe is worn away on 
its inner side. Weak ankles are very common in young children 
and are often one of the results of general weakness due to defec- 
tive assimilation. At this age the foot is, in addition, usually 
flat (Fig. 443), but in the valgus or weak ankle of later years 
the arch is often practically normal in outline. 

Outgrown Joints.- — In older children "outgrown" joints often 
attract the mother's attention; the internal malleoli appear promi- 
nent because of the position of valgus, or because of the turning 
out of the feet the malleoli may strike against one another, 
"interfere," and thus there may be an actual hypertrophy of 
the projecting bones from local irritation. 

Another type is the long, slender abducted foot, in which the 
inward bulging at the mediotarsal joint is indicated by the point 
of wear in the leather of the shoe (Fig. 440). 

In the weak foot of childhood, although restriction of voluntary 
and passive motion may be present, there are, as a rule, but little 
local sensitiveness and muscular spasm, and, as has been said, but 
little actual pain, for the reason that the weak foot in childhood is 
not subjected to the strain of constant occupation or to the burden 
of an overweighted body. There is also another important 
difference: the foot of the adult is obliged to bear greater 
strain than any other part, and although normal in structure it 
may be overworked, so that in many instances the weakness of 
the foot is the only disability. But in childhood, when such 
exciting causes are absent, a weak foot is very often a local 
indication of general weakness and loss of tone. 

Irregular Forms of Weak Feet.— Occasionally the apex of 
the inward bulging and deformity is not at the mediotarsal joint, 
but anterior to it in the cuneiform region. In such cases the 
internal cuneiform bone may be enlarged and sensitive to pressure. 

Another form is the combination of a plantar flexed toe with a 
depressed arch (Fig. 446). Extreme deformity of this class is 
usually congenital. A milder type is not uncommon. (See Hallux 
Rigidus.) 

Weak Feet and Deformity of the Legs.— In childhood weak 
feet are often seen in combination with slight knock-knee (Fig. 
443), while in later life knock-knee usually induces in compensa- 
tion the opposite attitude of adduction. (See Knock-knee.) 
Bow-leg in childhood is usually accompanied by slight inward 
rotation of the feet, but later there is usually a certain degree 
of compensatory valgus, although it does not, as a rule, cause 
discomfort. 



696 



ORTHOPEDIC SURGERY 



General Weakness.— The direct effects of the weak and pain- 
ful foot have been described in detail. It must be borne in mind 
that the feet are the foundation of the body, and that an insecure 
foundation affects the entire mechanism. General functional 
weakness and awkwardness, the flat chest, round shoulders, or 
other curvatures of the spine, are often observed as accompani- 
ments or effects of weak feet. Thus, as a rule, the systematic 
treatment of any form of postural weakness must include the 
treatment of the feet as well. 

Recapitulation. — The disability and deformity of the weak 
or so-called flat-foot are caused by a disproportion between the 




Congenital flat-foot. Rigid deformity of 
an extreme type, illustrating the component 
abduction and obliteration of the arch. 



Flat-foot illustrating extreme deformity in 
childhood. 



strength of the foot and the weight and strain to which it is sub- 
jected. 

The foot may be weakened by injury or disease; it may be 
overburdened by the body weight, or overstrained by laborious 
occupation, or the broken-down foot may be simply one indica- 
tion of general bodily weakness. It is unnecessary to enumerate 
all the various factors that singly or combined lead to this dis- 
ability. It may be stated, however, that in adult life the weak 
foot is in many or most instances the only disability that demands 
treatment. Its most constant predisposing causes are the direct 



DISABILITIES AND DEFORMITIES OF THE FOOT 697 

injury caused by improper shoes and the mechanical disadvantages 
to which it is subjected by the assumption of improper attitudes. 

All weak or flat feet are mechanically weak, but all weak feet 
are by no means painful feet. Pain, the symptom of over-strain 
or injury, bears no definite relation to the degree of deformity. 

In certain instances persistent abduction of the foot may be 
accompanied by exaggeration of the arch; in others, the flattening of 
the arch may be the most noticeable deformity, but in most cases 
the two are combined in varying degree. And as each deformity 
is an evidence of weakness, it seems hardly necessary to make a 
radical distinction between the two, except as regards prognosis. 
For the abducted foot in which the arch is intact is almost always 




Hammer-toe flat-foot. 

an acquired deformity of short duration, whereas in the case of 
the foot in which the arch is obliterated the deformity usually 
dates from early childhood, and it is, therefore, less amenable to 
treatment as far as perfect cure is concerned. 

Treatment. — The principles of the treatment which leads to 
the permanent cure of the weak and deformed foot are very 
simple, but the application varies somewhat according to the 
grade and duration of the deformity. The object of treatment 
is to so change the weak foot that it may conform not only in 
contour but in habitual attitudes and in power of voluntary 
motion to the normal foot, because complete cure is impossible 
unless normal function is regained. The first step must be, 
therefore, to make passive motion free and painless to the normal 



698 OB THOPEDIC S UB GEB Y 

limit. In other words, the obstructions to the motion of the 
machine must be removed before the power can be properly 
applied; for the increase of muscular strength and ability, on 
which ultimate cure depends, is not possible while motion is 
restrained by deformity or by pain or by adhesions or contractions. 

The weak foot, because of inefficient ligaments and muscles 
unable to hold itself in proper position, must be supported until 
regenerative changes have taken place in its structure. Such sup- 
port is necessary to retain the joints in normal position, and to 
hold the weight in proper relation to the foot, otherwise normal 
function is impossible. When these essentials are provided the 
patient may cure himself by the proper functional use of the 
foot and by the avoidance of attitudes that place it at a dis- 
advantage. 

It may be well to describe, first, the treatment that must be 
applied to all classes of weak foot in which a cure is to be attempted 
and which by itself is sufficient in the milder types, before calling 
attention to the modifications that may be necessary in more 
advanced cases. 

The Shoe. — In all cases it will be necessary to provide the 
patient with a proper shoe, for the shoe is usually the direct 
cause of the minor deformities, and indirectly, in many instances, 
of more serious disability. Indeed, most of the deformities and 
disabilities of the foot are incidental to civilization, and are, there- 
fore, confined to the shoe-wearing people. The direct effect of the 
ordinary shoe is to lessen the area and the adjustability of the 
fulcrum by cramping the toes. Indirectly it causes deformities — 
corns, bunions, and the like — which serve to make active move- 
ment or leverage painful, so that it is replaced by the passive 
attitude. 

The proper shoe should contain sufficient space for the inde- 
pendent movements of the toes. This motion is illustrated in the 
walk of the barefoot child. As the weight falls on the foot the 
toes spread, and as the body is raised on the foot they contract. 
The important leverage action of the great toe and the support 
afforded by it to the arch of the foot have been mentioned already. 
The shape of the sole should correspond to the shape of the 
foot and the heel should be broad and low. It will be noted that 
the front of the sole of the shoe in (Fig. 447) appears to be 
pointed slightly inward. Such a shoe aids in preventing abduc- 
tion, and it is, therefore, an important adjunct to the brace in 
restraining deformity. 



DISABILITIES AND DEFORMITIES OF THE FOOT 699 



Raising the Inner Border of the Shoe. — A simple expedient in 
the treatment of the weak foot and an aid in balancing it properly 
is to make the inner border of the sole and heel of the shoe slightly 
thicker in order to throw the weight toward the outer side of the 
foot. This is of special importance in the treatment of the slighter 
degrees of what is known as weak ankle, and it is always of ser- 
vice in the treatment of any grade of weak foot. 

Attitudes. — The patient's attention is then called to the signifi- 
cance of the bulging on the inner side of the foot (Fig. 441) and 
how this may be prevented by throw- 
ing the weight on the outer side of the FlG ' 44T 
foot (Fig. 442) and by holding the feet 
parallel with one another in walking 
(Fig. 417). The importance of lever- 
age is shown him, that he must try to 
press down the sole of the shoe with 
his toes, particularly with the great 
toe, and employ the active lift of the 
calf muscles by fully extending the leg 
and raising the body on the foot from 
time to time (Fig. 417). Finally, he 
must avoid long continuance in one 
position, especially the passive posture, 
which, even in the normal subject, 
simulates the attitude and deformity 
of weak foot. In short, he must be 
instructed in the mechanics of the foot 
and taught how the weak foot may be 
protected as well as strengthened. 

Exercises. — It is important, also, to 
demonstrate to the patient the normal 
range of motion of the foot, motion 
which, if restricted, must be regained 
by voluntary and passive exercises. 
Voluntary exercise should be devoted 
to strengthening the adductors and 
plantar flexors; thus the foot should 
be adducted and inverted, then dorsi- 
flexed in the attitude of slight adduction (Fig. 421) over and 
over again at every opportunity. Tip-toe exercises are especially 
useful; the patient, placing the feet in the attitude of moderate 
inward rotation, raises the body on the toes to the extreme 




The proper relation of the sole to 
the shape of the foot: A, outline 
of sole; B, outline of foot; C, im- 
print of foot. 



700 



OR THOPEDIC SURGERY 



limit, the limbs being fully extended at the knees, then sinking 
slowly, resting the weight on the outer borders of the feet, in 
the attitude of marked varus, twenty to one hundred times. This 
exercise is somewhat difficult, and it cannot be carried out 
properly if there is any limitation of motion or sensitiveness at 
the mediotarsal joints. The best of all exercises is, however, the 
proper walk, in which the leverage power of the foot is employed 
and in which it passes through the proper alternation of postures 




The tip-toe exercise, raising the body on the 
adducted feet. (See Fig. 449.) 



The tip-toe exercise, resting on the outer 
borders of the feet. (See Fig. 448.) 



(Fig. 417). Treatment by massage and special gymnastic exer- 
cises is, of course, of benefit if the patient can command it, although 
by no means essential to the cure. 

Support. — In many instances the simple treatment that has been 
outlined is all that is required, but in the majority of cases the 
patient is not able to prevent deformity voluntarily; consequently 
a support is necessary to hold the foot in proper position and to 
relieve discomfort. It is usually necessary in the treatment of the 



DISABILITIES AND DEFORMITIES OF THE FOOT 701 

weak foot of childhood because one cannot command the aid of 
the patient. 

In selecting a support for the weak foot the nature of the 
deformity should be borne in mind; that the acquired flat-foot, 
for example, is not a direct breaking down of the arch, as is 
usually taught, but a lateral deviation and sinking — a compound 
deformity, as has been already described (Fig. 436). Thus a 
brace to be efficient must hold the foot laterally as well as support 
the arch. But it must not prevent the normal motions of the foot, 
and thus interfere with the increase of muscular strength and 
ability, on which ultimate cure depends. 

The supports that are ordinarily used for flat-foot do not fulfil the 
conditions; the pads, springs, and plates placed beneath the arch 
are intended to support it by direct pressure without regard to the 




The attitude in which the plaster cast should be taken. This attitude is important, 
because in it the foot assumes the best possible contour. If the sole is simply pressed 
downward into the plaster cream, the ordinary method of making the model, the shape 
will be found to be quite different from that taken in the manner illustrated. 



abduction ; they are usually ill-fitting, and are often of such length 
and shape as to splint the foot and thus to restrict its motion. 
Leg braces which control the valgus do not often hold the foot 
accurately, and their weight and unsightliness are fatal objec- 
tions to their use, especially in the early cases, in which pre- 
vention of subsequent deformity is of such importance. 

A brace should never be applied to a deformed and rigid foot 
because it cannot adapt itself to the support; the spasm and 
rigidity should be first relieved by the preliminary treatment, 
that will be described in the consideration of this class of cases. 

The Construction of the Brace. — To properly construct a brace 
to meet these conditions, it is necessary to provide the mechanic 
with a plaster cast of the foot, taken in the attitude in which one 
wishes to support it. Such a model may be easily and quickly 
made in the following manner: 



702 ORTHOPEDIC SURGERY 

The Plaster Cast. — Seat the patient inachair; in front of him place 
another chair somewhat less in height; on it lay a thick pad of cot- 
ton-batting and cover it with a square of cotton cloth. Put about 
a quart of cold water into a basin and sprinkle plaster-of-Paris 
on the surface until it does not readily sink to the bottom; then 
stir. When the mixture is of the consistency of very thick cream 
pour it upon the cloth. The patient's knee is then flexed, and 
the outer side of the foot, previously rubbed with talcum powder, 
is allowed to sink into the plaster, and, the borders of the cloth 
being raised, the plaster is pressed against the foot until rather more 
than half is covered. The foot should be at an angle with the leg, 
corresponding to its usual position in the shoe, that is slightly 
plantar flexed, and the sole should be in the plane perpendicular 
to the seat of the chair (Fig. 450). As soon as the plaster is hard 




A, the] astragalonavicular joint. The internal flange of the brace should rise well above 
all the prominent bones to a point about half an inch below the malleolus. 

its upper surface is coated with vaseline, and the remainder of 
the foot is covered with plaster; the two halves are then removed, 
smeared lightly with vaseline, and bandaged together. The 
interior is dampened with soapsuds, and it is then filled with 
the plaster cream. In a few moments the plaster shell may be 
removed, and one has a reproduction of the foot, which, when 
properly made, should stand upright without inclination to one 
side or the other (Fig. 454). 

In most instances it will be of advantage to deepen in the plaster 
model the inner and outer segments of the arch, in order that 
the arch of the brace may be slightly exaggerated, especially 
at the heel, so that the depression of the anterior extremity of 
the os calcis may be prevented. If the outer border of the cast 
is flattened by pressure a little plaster should be added to approxi- 
mate the normal contour. 



DISABILITIES AND DEFORMITIES OF THE FOOT 703 

The Brace. — Upon the model the outline of the brace is drawn 
as illustrated in the diagrams. The best sheet steel, 18 to 20 
gauge, cut after the pattern is moulded upon it and tempered, so 
that as it is applied for the purpose of preventing deformity, it 
may be practically unyielding to the weight of the body. 

It will be noticed that the brace clasps the weak part of the foot 
and holds it together; the broad internal upright portion (Fig. 
451) covers and protects the astragalonavicular junction, rising 
well above the navicular; the external arm covers the calcaneo- 
cuboid junction and the outer aspect of the foot to a height suffi- 
cient to hold the foot securely (Fig. 452). The sole part provides 




B, the calcaneocuboid junction. The external flange 
extends from the centre of the heel to a point just be- 
hind the base of the fifth metatarsal bone. 




C, the great toe-joint; D, the 
centre of the heel. 



a firm, comfortable support, yet, reaching only from the centre 
of the heel to just behind the ball of the great toe, it does not 
restrain the normal motions of the foot (Fig. 453). The brace 
may be nickel-plated which makes a smooth finish, or galvanized, 
which makes a more durable covering. It may be covered with 
leather, or an inner sole may be placed on its upper surface; 
but this is not usually necessary. As it is fitted to the foot, it 
finds and holds its own place in the shoe, so that no attachment 
is required; thus it may be changed from one shoe to another. 
Not only does it hold the foot laterally and from beneath, but 
there is an element of suggestiveness in the slight leverage action 
which is very important, and which is a distinctive feature of 
this brace as contrasted with simple sole plates or other supports. 



704 



OB THOPEDIG S UB GEB Y 



The Positive Action of a Proper Brace. — The patient, instructed 
to throw his weight upon the outer side of the foot and wear- 
ing the shoe which has been tilted in the same direction by 
thickening the inner border of the sole and heel, presses down 
the external arm and thus lifts the internal flange against the 
inner side of the foot, which is instinctively drawn away from 
the pressure and thus toward the normal contour. He no longer 
turns the feet outward in walking, because this causes positive 
discomfort, and he is not likely to assume the passive attitude 
because of the suggestive lateral pressure of the support. With 
the foot held in the normal attitude the patient may again walk 
with the proper spring; thus the brace itself becomes a positive 
aid in the physiological cure. It is important, also, that a shoe 




A cast marked for the mechanic. In most instances the internal flange is lengthened as 
in this diagram, as compared with Fig. 451, in order to strengthen the support so that light 
steel (gauge 20) may be used. (See Fig. 455.) 



of proper shape, as shown in the diagram (Fig. 447), be worn, 
as it aids the brace in holding the foot in an attitude of slight 
adduction. 

The shape of the brace, in general like that of the diagram, is 
modified in certain cases; for instance, the entire internal aspect 
of the foot may be weak and must be covered by the internal 
flange. In very heavy subjects the sole portion must be made 
larger, although this is a disadvantage, as it lessens the leverage 
action; other slight modifications may be necessary in special 
cases. If any portion of the rim of the brace causes discomfort, 
the edge may be turned away slightly at the point of pressure by 
a wrench. After a few days the patient no longer notices the 
constraint of the brace, and as its presence in the shoe is not 
evident, it may be worn indefinitely. Steel is the lightest and 



DISABILITIES AND DEFORMITIES OF THE FOOT 705 






strongest, and, on the whole, the most satisfactory material for the 
brace. It will, of course, rust in time, and for this reason each 
patient may be provided with two pairs of braces, in order that 
the rusted pair may be returned to the bracemaker for repairs. 
In hospital practice heavier material is used and the braces are 
plated with tin, which is fairly resistant. 1 

Support is usually necessary for from three months to a year or 
longer according to the condition of the patient and the strain to 
which the feet are subjected. The brace, accurately made and ad- 
justed under suitable conditions, 
causes no more pressure or dis- 
comfort than a well-made shoe, for 
its principle is quite different from 
that of the ordinary supports that 
are in common use, to which this 
objection has been made. This 
'brace supports the arch primarily 
by preventing abduction, con- 
sequently its pressure is first felt 
upon the lateral aspect of the foot, 
a pressure that the patient can 
relieve by improving his attitude. 
The brace should afford support 
when necessary, and at all times 
suggest and enforce a proper 
attitude; it is, however, but one of 
the essential factors in the general 
scheme of treatment. The ordinary form of brace in all its modi- 
fications conforms to the shape of an inner sole (Fig. 456). As it 
supports the sole of the foot, and by the elevation of its inner border 




The outline of the sole part of the brace. 






The sole plate ordinarily used in the treatment of weak foot. (After Bradford and Lovett.) 

tends to throw the weight more toward the outer side, it is a 
useful aid in treatment ; but, providing no lateral support, it cannot 
prevent the inward bulging of the foot, which is the most im- 

1 In many instances there is a rapid improvement in the shape of the foot under treatment, 
and it is often advisable to make a second cast in such cases, in order that the brace may 
ponform to the improved contour. 

45 



706 ORTHOPEDIC SURGERY 

portant element of the deformity, and as compared to the brace 
described, it is therefore an ineffective apparatus. 

In the treatment of children the foot should be moved in all 
directions, but particularly in dorsal flexion and adduction to the 
full limit at morning and at night, until the child has regained 
the normal muscular power and ability. Special gymnastics and 
massage are always desirable, and they may be necessary in 
certain cases. Bicycling may be cited as one of the best, and 
roller-skating as one of the worst exercises for the weak foot. 
A year is about the time required for a cure of the weak foot in 
childhood, although attention to the shoes and to the attitudes 
must be continued indefinitely. 

The Rigid Weak Foot. 

One may now contrast with the mild types of weakness that 
have been described the cases of extreme deformity in which 
the symptoms are disabling and in which the foot is rigidly held 
in the deformed position by muscular spasm and by secondary 
changes in its structure. Such cases, often considered hopeless 
as regards a cure or even relief, are in reality the most satisfac- 
tory from the remedial standpoint, and in no other type of pain- 
ful deformity can so much be accomplished by rational treatment 
as in this class. The deformity must be considered as a disloca- 
tion in which the astragalus has slipped downward and inward 
from off the os calcis, which, in turn, is tipped downward and 
inward and into a position of valgus. The remainder of the 
foot is turned outward, so that the relation of the leg and the 
forefoot is entirely changed; in fact, the forefoot is almost entirely 
disused (Fig. 445). 

Corresponding to the duration of the disability, one finds 
accommodative changes in the soft, parts and in the bones, but 
such changes are by no means as marked as those recorded in the 
reports of autopsies which have been made in cases of advanced 
and irremediable deformity. In fact, by far the greater number of 
patients are young adults in whom the extreme deformity is of com- 
paratively short duration, and in whom complete cure is possible. 

In the treatment of such a condition one must first reduce the 
dislocation and overcome the obstacles that contracted muscles and 
ligaments may offer to free and normal motion; then rest must 
be assured to the injured and congested parts in order to relieve 
the patient from the pain from which he has suffered so long. 



DISABILITIES AND DEFORMITIES OF THE FOOT 707 

Forcible Overcorrection. — By far the most effective treatment is 
forcible overcorrection of the deformity, under anaesthesia. When 
the patient is under the influence of the anaesthetic the muscular 
spasm relaxes, and it will be seen that this accounts for about 
half of the restriction of motion, the remainder being caused by the 
adaptive changes that have been mentioned. The object of the 
operation is to overcome the residual obstruction, and to assure 
the patient against a relapse, by fixing the foot for a sufficient 
time in the position of extreme adduction and supination, the 
attitude directly opposed to that which has become habitual. 

This is the object of forcible overcorrection as the first step in 
the systematic repair of the disabled mechanism; its principle 

Fig. 457 Fig. 458 





The deformed foot before operation. A, the The overcorrected foot, showing the 

projection of the displaced astragalus and navic- reversal of the lines of displacement. 
ular; B, the inner malleolus; C, the medio- (See Fig. 459.) 
tarsal joint, showing the outward displacement 
before, the inward rotation behind, this point. 

must not be confounded with forcible correction carried out with 
the object of simply remoulding the arch of the foot, or in which 
the correction of the deformity is the only object in view. 

One first extends the foot forcibly, then flexes it to the normal 
limit, then abducts and adducts, the different motions being 
carried out over and over until the rigid foot has become perfectly 
flexible. In cases of long standing it is often necessary to draw 
the patient to the end of the table, so that the foot may be taken 
between the knees, in order to supply the required force by the 
thigh muscles. This forcible manipulation is accompanied by the 
audible breaking of adhesions, and in favorable cases by complete 
disappearance of the deformity. In certain instances it will be 



708 ORTHOPEDIC SURGERY 

necessary to divide the tendo Achillis, when, for example, the 
range of dorsal flexion is limited by resistant accommodative 
shortening of the calf muscles, or when there has been very great 
pain and tenderness at the mediotarsal joint, and it is desired to 
remove the strain of leverage completely; traumatic cases come 
especially under this head. Tenotomy has one great advantage: 
it necessitates longer fixation in the plaster bandage, and gives 
the patient the benefit of rest, and the opportunity for prolonged 
after-treatment. When the passive range of motion has been 
regained, the foot is turned downward, then inward and upward 
into the position of extreme varus. By this manipulation the os 
calcis is drawn under the astragalus and thrown into the supinated 
position, and the ravicular is flexed about and under the head of 
the astragalus, which is then lifted to the limit of normal flexion. 
The attempt is always made to bring the extreme outer border 
of the inverted foot up to a right angle with the leg, which is the 
limit of normal flexion in this attitude. The foot, very thickly 
padded with cotton, especially between and about the toes, is then 
fixed in this posture of varus by a firm plaster-of-Paris bandage 
extending to the knee (Fig. 459). Surprisingly little discomfort, 
considering the force that it is sometimes necessary to apply, is 
experienced after the operation. The familiar and often intense 
pain, from which the patient has suffered so long, is entirely 
relieved by the correction of the deformity; there is often a sense 
of tension about the outer side of the ankle and dorsum of the 
foot, but this is not, as a rule, of long duration. 

Functional Use in the Overcorrected Attitude. — As soon as pos- 
sible, often on the following day, the patient is encouraged to stand 
and walk, bearing his weight on the foot. Weight bearing serves 
to still further overcorrect the deformity and to accustom the 
patient to a posture entirely different from that so long assumed. 
Meanwhile, the contracted tissues on the outer side become 
thoroughly overstretched; the weakened ligaments and muscles 
on the inner side are relaxed, and the local irritation rapidly 
subsides under the rest from the constant injury to which the 
foot has been subjected. 

The patient is not confined to the bed or house, although if 
both feet are in plaster bandages, crutches are, of course, neces- 
sary. The time that the foot should remain in the overcorrected 
position depends upon the duration of the deformity and the 
severity of . the symptoms, from two to six weeks, the usual 
time being about four weeks. At the end of about three weeks, 



DISABILITIES AND DEFORMITIES OF THE FOOT 709 



or whenever the patient can support the weight on the plaster 
bandage, without a sensation of discomfort, it is removed; the 
foot is placed in the normal attitude and a cast is taken for 
the brace (Fig. 450). Immediately after, the foot is returned 
to the former position and the plaster bandage is reapplied. 
When the brace is ready the plaster bandage is finally removed; 
the foot is now in good position, and in many instances the arch 
is exaggerated in depth. For the first few days prolonged soak- 
ing in hot water or the use of the hot-air bath, with subsequent 
massage at intervals during the 

day, will be found useful in over- FlG ' 459 

coming the swelling and sensi- 
tiveness that may remain. It is 
always insisted that a new shoe 
of the Waukenphast pattern shall 
be obtained, the sole and heel of 
which are raised a quarter of an 
inch on the inner border to aid 
in the balancing of the weak 
foot. The brace is then applied , 
and the patient is never allowed 
to walk without its support. 
When the shoe is removed at 
night, he is instructed to turn 
the toes in and to bear the 
weight on the outer side of the 
foot until it has regained its 
strength; in other words, the de- 
formity is never allowed to recur. 
Systematic Manipulation. — 
Systematic treatment is . then 
begun by the surgeon and the 
patient, with the object of re- 
storing free and painless passive movement in all directions. This 
movement, which has been so long restrained by deformity, cannot 
be regained without effort, and during this critical stage, treat- 
ment must be carried out by the surgeon himself; if he trusts to 
the patient or to his friends a cure is out of the question. At 
least once a day the full range of motion must be carried out to 
the normal limit. Three motions — abduction, flexion, and exten- 
sion — are usually free and painless; but the fourth, that of 
adduction, is almost invariably resisted by the same quality of 




The forcible overcorrection of flat-foot. The 
, proper position in the plaster bandage. 



710 



OB THOPEDIO S UB GEB Y 



muscular rigidity that was present before the operation. Per- 
haps the only effective method of overcoming this resistance is 
conducted as follows: The patient being seated in a chair, the 
surgeon sits or stands before him. Let us suppose that the 
right foot is to be adducted, or, as the patients express it, twisted. 




JTwisting" the foot. 



The surgeon places the foot between his knees; his right hand 
encircles the heel, the fingers grasping the projecting os calcis 
and tendo Achillis; the base of the palm lies against the medio- 
tarsal joint on the inner and inferior aspect of the foot; the left 
hand grasps the outer side of the forefoot and toes; then, by 
steady pressure of the thigh muscles, the forefoot is forced 



DISABILITIES AND DEFORMITIES OF THE FOOT 71 1 

downward and inward (adducted and supinated) (Fig. 460) over 
the fulcrum formed by the projecting palm, which lies upon the 
right knee, the fingers holding the heel steadily in place. This 
inward twisting is at first resisted by voluntary and involuntary 
muscular spasm, which gradually gives way under steady pres- 
sure. When the limit of adduction has been reached, the foot 
is held firmly until all pain has subsided; then the patient is in- 
structed to attempt voluntary movements while the foot is guided 
by the hands; in other words, the patient attempts to adduct 




Method of applying the plaster strapping to hold the foot in the adducted attitude. 

the foot while the surgeon supplies the power, which in all cases 
of this type has been completely lost. This passive manipula- 
tion to the extreme limit of normal adduction, plantar and dorsal 
flexion, is continued from day to day until there is no longer a 
sensation of pain or tension. For as long as there is the slightest 
spasm or painful restriction of passive motion, the voluntary 
assumption of proper attitudes is checked, and until this power 
is regained there is danger of relapse. During active treatment, 
therefore, the patient, by means of massage and active and pas- 
sive exercises, must constantly work to one end, namely, to regain 
the lost power of voluntary adduction. 



712 ORTHOPEDIC SURGERY 

The time necessary to rest the feet, to overcome the local irrita- 
tion and muscular spasm, to regain, in part at least, the range 
of passive motion, and to place the patient in the same position, 
as regards a cure, as in the milder types of deformity, is from 
three to six weeks. Usually the patients are told that a month 
will be necessary, and that at the end of that time they may return 
to work, free from pain and from the danger of relapse, and that 
the feet will constantly grow stronger under the work which was 
before too great for their strength. The time necessary to re- 
educate the adductor muscles in their proper function depends, 
in great degree, upon the intelligence and persistence of the patient. 
Although in after-treatment massage and special exercises are 
of benefit, the essentials are very simple; they are an effective 
brace, a proper shoe, the passive manipulation that has been 
described until its object has been attained, and the proper walk, 
the best and easiest of exercises. Finally, one must force into 
the patient's understanding the method of protecting the weak 
foot by the alternation of strain, and by proper postures. 

Other Varieties of Rigid "Weak Foot.— The foot which is fixed 
in the abducted position without depression of the longitudinal 
arch is simply one variety of the rigid weak foot, which should 
be treated in the same manner. It may be stated, also, that a 
very large proportion of the so-called chronic sprains of the ankle 
are of this type, and that the disability will yield very readily to 
treatment, conducted with the purpose of restoring impaired func- 
tion, in the manner that has been indicated. 

In certain instances the apex of the deformity lies in front 
of the astragalonavicular joint, in the navicular cuneiform region, 
and the internal cuneiform bone may be enlarged and sensitive 
to pressure. Such cases should be treated on the same general 
principles as the ordinary variety. 

In rare instances marked depression of the arch is accompanied 
by flexion contraction of the great toe, as if the result of an attempt 
to support the weak arch. This was described by Nicoladoni 
as hammer-toe flat-foot (Fig. 446). The association of painful 
great toe (hallux rigidus) and weak foot is mentioned elsewhere 
(page 735). 

There are other cases in which the deformity of weak foot is 
complicated by rheumatoid arthritis or chronic rheumatism, or 
similar affections of which the evidence is seen in various joints, 
but in which the pain and discomfort seem to be concentrated 
in the feet, which are absolutely stiff and deformed. In such 



DISABILITIES AND DEFORMITIES OF THE FOOT 713 

cases one can hardly expect a complete cure; but although the 
function of leverage may not be regained, still one may hope, by 
overcoming the deformity, to hold the weight of the body in its 
proper relation to the foot, so that the pain of a progressive dis- 
location may not be added to the pain of disease. In a number 
of instances forcible correction has been employed by the writer 
in cases of this type, and in all the improvement in the general 
condition, consequently in the resistance to the disease, after the 
relief of the local pain and discomfort, has been very great. 

Between the two classes of cases, the mild and the severe, one 
finds every grade of deformity. All cases in which there is marked 
muscular spasm, local sensitiveness, and swelling require tem- 
porary rest; in many instances simply rest from functional use 
combined with massage; in others, rest in a plaster bandage 
in the adducted attitude. In the milder and ordinary class of 
cases the use of a brace and shoe will relieve spasm and pain, 
and the range of motion can usually be regained by manipulation, 
passive motion, and by the proper use of the foot. 

Occasionally, even in childhood, one may encounter marked 
limitation of normal motion, particularly in dorsal flexion, caused 
by actual shortening of the muscles. This may be the accommo- 
dative adaptation characteristic of long-standing deformity; in 
other instances it would appear to be the result of a slight and 
unnoticed neuritis or anterior poliomyelitis, which has resulted in 
muscular inequality. If the contraction does not yield readily 
to manipulation or to mechanical stretching, forcible correction 
and, if necessary, tenotomy should be employed in the manner 
already described; for whatever may be the cause it is again 
emphasized that obstruction to motion in every direction must 
be overcome before a complete cure is possible. 

Adjuncts in Treatment. — It must be apparent that in many 
instances the anatomical cure of the weak foot is impracticable, 
either because of the want of energy or opportunity on the part 
of the patient, or because of the local or general conditions, types 
familiar in out-patient practice. 

The Thomas Treatment. — In such cases raising and strengthening 
the inner side of the shoe by the wedge-shaped leather sole, as 
used by Thomas, splints the painful foot and aids in relieving the 
strain. 

Plaster Strapping. — If the symptoms are more acute the adhe- 
sive plaster strapping, as advocated by Cottrell and Gibney 
for the treatment of sprains, is often of service, although it is 



714 OB THOPEDIC S UB GEB Y 

applied in a different manner, and with a different object in 
view. One end of a strip of adhesive plaster, about fifteen inches 
long and three inches wide, is applied to the outer side of the 
ankle just below the external malleolus; the foot is then adducted 
as far as possible, and the band is drawn tightly beneath the 
sole up the inner side of the arch and leg, and is stayed in this 
position by one or two plaster strips about the calf (Fig. 461). 
Narrow plaster straps are then applied about the arch and ankle, 
in the figure-of-eight manner, and a bandage is applied. The 
object of the dressing is to aid in holding the foot in the improved 
position by the support and suggestiveness of the plaster, and to 
provide the firm compression about the arch that is always agree- 
able to the sufferer from weak foot. This treatment, combined 
with the built-up shoe, is often very effective in overcoming the 
acute and disabling symptoms of the weak and injured foot, which 
are, as has been stated, often the result of extra strain or injury; in 
other words, a sprain of a weak foot. Consequently, when these 
symptoms are relieved, the patient who has become habituated 
to the weakness and deformity considers himself cured. By per- 
sistent manipulation and subsequent support with the adhesive 
plaster one may overcome the deformity in the majority of cases. 
When this is accomplished the brace is applied and the further 
treatment that has been described is continued. Forcible correc- 
tion under anaesthesia is, however, preferable in cases of the more 
resistant type. 

Operative Treatment. — The various cutting operations for the 
relief of flat-foot do not call for extended comment. The typical 
operation, the removal of a wedge from the astragalonavicular 
region, aims simply at removal of the deformity. It should be 
restricted to those cases in which the adaptive changes are so 
marked that functional cure is impossible. 

The operation of advancement of the posterior extremity of the 
os calcis, as proposed by Gleich, in order that it may be placed 
in relation to the leg somewhat like that of a Pirogoff amputa- 
tion, offers little hope of ultimate cure; for since the disability 
is not due to primary depression of the arch, it can hardly be 
cured by exaggerating its depth in this manner. Supramalleolar 
osteotomy, in which the bones of the leg are divided above the 
ankle, and the distal extremity turned inward, with the aim of 
directing the weight toward the outer border of the foot, has been 
advocated by Trendelenburg. In practice the operation is by no 
means always successful, while the bow-leg deformity that results 



DISABILITIES AND DEFORMITIES OF THE FOOT 715 

if the object is attained is an unfortunate accompaniment of the 
treatment. It may be mentioned in this connection that fracture 
at the ankle-joint, followed by faulty union in a position of valgus, 
is a form of traumatic weak foot that may be cured by this opera- 
tion. In operative treatment the element of rest, necessary for 
weeks or months, must be taken into consideration, as explaining 
in part the immediate favorable effect of whatever procedure is 
adopted. 

In conclusion, the following points are again emphasized: 
flat-foot in its surgical sense is a compound deformity, in which 
the abnormal relation between the foot and the leg, causing the 
improper distribution of the weight and the strain and disuse of 
normal function, is of vastly greater importance than the depres- 
sion of the arch, which has given the name to the disability. 

The weak and deformed foot can be cured, but only by the 
application of the simple principles that any mechanic would 
apply to a disabled machine whose structure and use were known 
to him. In other words, there can be no permanent cure of weak- 
ness and deformity unless normal function is regained, or effective 
treatment unless it has this end in view. 

The term weak foot has this advantage over others that imply 
deformity, in that it may be properly applied to the earliest in- 
dications of disability. Once weakness is recognized, its causes 
may be analyzed and appreciated at their proper value. Flat-foot 
is a particularly objectionable and misleading term, and it should 
be discarded or at least used only to describe those cases to which 
it can properly be applied. 



CHAPTER XXI. 

DISABILITIES AND DEFORMITIES OF THE FOOT (Continued). 

The Hollow or Contracted Foot. 

Synonyms. — Non-deforming club-foot, talipes arcuatus, talipes 
plantaris, talipes cavus. 

The depth of the arch and the corresponding area of the bear- 
ing surface of the foot vary greatly in different individuals, and, 
although marked differences in contour and function are possible 
within a normal range, yet, as a rule, the low arch is character- 
ized by relaxation and weakness of structure, while the exaggerated 
arch implies a corresponding contraction and loss of normal 
elasticity. 

The hollow or contracted foot may be divided into two classes 
— the primary and the secondary. In the first class the simple 
exaggeration of the arch (talipes arcuatus) is the only change 
from the normal condition. In the second the high arch is com- 
bined with limitation of the range of dorsal flexion at the ankle- 
joint (talipes plantaris — Fisher). 

Etiology. — The simple hollow foot may be an inherited pecu- 
liarity. The depth of the arch may be exaggerated by the habitual 
use of high heels (postural equinus), or by excessive use of the 
calf muscles, as by professional dancers. 

The secondary variety, in which the hollow foot is combined 
with slight equinus, may be induced by habitual use of high heels, 
but if it is marked its origin may be traced in many instances to 
a mild and transient form of anterior poliomyelitis or neuritis 
in early childhood. This causes temporary weakness of the 
anterior group of muscles of the leg, and thus a slight toe-drop, 
followed by secondary contraction of the tissues of the sole and 
of the muscles of the calf. In the history of many of these patients 
it will appear that after recovery from scarlatina or other con- 
tagious or infectious disease the child seemed weak or awkward. 
These symptoms became less marked or practically disappeared; 
yet a trace remained, although not of sufficient importance to call 
for treatment, until adolescence or adult life, when the greater 



DISABILITIES AND DEFORMITIES OF THE FOOT 717 

strain and weight put upon the feet brought to light the latent 
disability. The affection may undoubtedly develop in later 
years as the result of neuritis, or of gout or rheumatism. It may 
be caused by a sprain or fracture of the ankle, and it may be a 
result of habitual posture in compensation for a limb shortened by 
injury or disease. 

The exaggerated arch which is a part of a more important 
deformity, as of equinovarus or calcaneus, or that which is simply 
one of many distortions caused by diseases of the nervous appa- 
ratus, does not belong to the class of disability under consideration. 




The contracted foot of slight degree. 

Symptoms. — The simple hollow foot often exists without 
symptoms; in fact, it is usually considered as a particularly well- 
formed foot rather than a deformity. The common complaint in 
these cases is that one is unable to buy comfortable shoes because 
the ordinary shoe does not support the arch, or because the 
leather presses on the dorsum of the foot. The convexity of the 
dorsum, of course, corresponds to the depth of the arch; in many 
instances the cuneiform bones project sharply beneath the skin, 
and painful pressure points or even inflamed bursee in this locality 
may cause discomfort. 



718 



ORTHOPEDIC SURGERY 



In the well-marked cases in which the weight is borne entirely 
on the heel and the front of the foot, calluses and corns usually 
form at the centre of the heel and beneath the heads of the 
metatarsal bones. The patient may complain of neuralgic pain 
about the great toe, the metatarsal arch, or in the sole of the foot. 
The gait is often ungraceful, as the patient walks heavily upon 
the heels with the feet turned outward. In such cases "the 
ankles may be weak and turn easily." In the more advanced 
cases of this type the foot may assume the position of valgus 




Contracted foot, marked. 



when weight is borne, so that the more noticeable symptoms are 
those of the weak foot or so-called flat-foot. 

Contracted foot, of the more severe grade, is almost always 
accompanied by a certain limitation of dorsal flexion; and as the 
shortening of the plantar fascia is often more marked at its inner 
border, a slight inversion of the forefoot or varus may be present 
also. 

When the exaggerated arch is combined with limitation of 
dorsal flexion the deformity is usually greater. This limitation 
may be very slight, or it may be well-marked; and a slight degree 
of permanent equinus even may be present, but so slight that it 
does not, as a rule, attract attention. 

This type of the contracted foot was first clearly described by 



DISABILITIES AND DEFORMITIES OF THE FOOT 719 

Shaffer, in 1885, under the title of "non-deforming club-foot," 1 
and later by Fisher, of London, as "talipes plantaris." 

The symptoms are similar to those of the simple hollow foot, 
but they are almost always more marked. The gait is awkward 
and jarring, the feet being turned outward to an exaggerated 
degree. The patient is easily fatigued, and often complains of the 
weakness about the ankle and inner side of the arch, characteristic 
of the weak foot, and of sensations of tire and strain in the calf 
of the leg. The discomfort from corns, the pain referred to the 
metatarsal region, the great toe, and to the sole of the foot have 
been described already. 

On examination the exaggeration of the arch is evident, and 
an imprint of the sole shows that the weight is borne entirely on 
the heel and on the heads of the metatarsal bones, which may be 
very prominent beneath the thickened skin, as if the subcuta- 
neous fat had been absorbed. The anterior metatarsal arch is 
often obliterated, and the toes are usually habitually dorsiflexed 
at the first phalanges, the permanent flexion, with the resulting 
pressure against the leather of the shoe being indicated by a row 
of corns upon their dorsal surfaces (Fig. 463). 

The contracted plantar fascia may be demonstrated by forcible 
dorsal flexion of the foot, when the tense bands, in many instances 
very sensitive to pressure, may be felt beneath the skin. 

On testing the movements of the foot, the limitation of dorsal 
flexion, both of the voluntary and the passive range, will be evi- 
dent. In voluntary flexion the toes are drawn up and the tendons 
are plainly seen on the dorsum, showing the effort made by the 
accessory muscles to overcome the abnormal resistance. 

The limitation of dorsal flexion may be demonstrated in the 
manner suggested by Shaffer, by asking the patient to flex the 
feet while standing erect with the back to the wall, when, in spite 
of the effort made, "the feet remain glued to the floor." 

Treatment. — In the ordinary form of contracted foot, as has 
been stated, the disability is much more marked than the defor- 
mity; and the disability is due to secondary changes in the struc- 
ture of the foot, by which its elasticity is impaired. If this can 
be restored in some degree permanent relief will follow. If the 
simple hollow foot (cavus), or the secondary type (plantaris), 
were discovered in early childhood, massage and methodical 
stretching would, in all probability, be sufficient to relieve the 
contractions; but, as a rule, no symptoms are noticed until later 

1 New York Medical Record, May 23, 18S5. 



720 ORTHOPEDIC SURGERY 

life. Even then, especially in the simple form, they are often 
slight and may be relieved by a shoe with a broad heel and a high 
(Spanish) arch or by a foot-plate that equalizes the pressure on 
the sole. 

In the more advanced cases of the milder type methodical 
forcible manual stretching may elongate the tissues sufficiently 
to relieve the symptoms. The Shaffer 1 "traction shoe" may be 
used with advantage for the same purpose. In the more resist- 
ant 'cases, however, division of the contracted parts and forcible 
correction of deformity are indicated. 

Operative Treatment. — The patient having been anaesthetized, 
a tenotomy knife is introduced beneath tjie skin to the inner side 
of the central band of fascia. This is divided by a sawing motion, 
and if on forced dorsal flexion other tense bands appear they 
are divided also. Forcible massage, with the aim of making 
the foot flexible and reducing the depth of the arch, is then 
employed. If more force is required the Thomas wrench 
may be used as in the treatment of club-foot; the object 
being to elongate the foot, to remove the contraction, and 
thus by increasing the area of bearing surface to relieve the 
painful pressure on the heads of the metatarsal bones. If the 
contraction of the tendo Achillis cannot be overcome by forcible 
manipulation it may be divided. The foot is then fixed in a 
well-fitting plaster bandage in an attitude of dorsal flexion, a 
thin board, shaped to the foot, having been incorporated in the 
bandage, in order that firm and even pressure may be exerted 
upon the sole. As soon as possible, often on the following day, 
the patient is encouraged to walk about, in order that the pressure 
of the body weight may be utilized to flatten the foot still more, 
while its tissues are in a yielding condition. 

The bandage may be continued for six weeks, or, if the tendo 
Achillis has been divided, until its repair is complete. A well- 
fitting shoe should be worn, and methodical massage and stretching 
of the tissues should be continued as long as the tendency to 
deformity remains. 

By this treatment the symptoms may be relieved, and in 
many instances a return to the normal shape and function can 
be assured. 

'New York Medical Journal, March 5, 1887. 



DISABILITIES AND DEFORMITIES OF THE FOOT 721 



Weakness of the Anterior Metatarsal Arch. 

Anterior Metatarsalgia and Morton's Neuralgia. — A peculiar 
spasmodic pain about the fourth toe was described by Morton, 
of Philadelphia, long before its predisposing and exciting causes 
were understood. For this reason a description of the symptoms 
may with advantage precede a consideration of the weakness of 
which they are usually the result. 

Typical cases of Morton's 1 painful affection of the foot are 
characterized by a sudden cramp-like pain in the region of the 
fourth metatarsophalangeal articulation. 

The pain may begin as a burning sensation beneath the toe, as 
a numb or tingling feeling, as a sudden cramp, or as a peculiar 
feeling of discomfort about the articulation that increases in 
severity until it becomes almost unbearable. At first the pain is 
confined to the neighborhood of the affected joint, but unless it 
is relieved it radiates to the extremity of the toe, to the dorsum 
of the foot, or up the leg. In many instances the onset of the 
pain is preceded by the sensation of something moving or slipping 
in the foot; in some cases the pain may be induced by sudden 
movements, missteps, or by long standing, and in practically all 
the cases the pain is felt only when the shoes are worn. The 
frequency of the recurrent cramp varies; in some cases it appears 
only at infrequent intervals; in others it practically disables the 
patient. When the "cramp" habit has been acquired, very slight 
causes may induce the pain — for example, a thin-soled shoe, a hot 
pavement, "the sticking of the sock to the foot," and the like — 
but, as has been stated, except in the very advanced and chronic 
cases, the pain is never felt except when the shoe is worn. 

To relieve the pain the patient removes the shoe, rubs and 
compresses the front of the foot, flexes and extends the toes, and 
the like. After the cramp is relieved a sensation of soreness 
remains, and occasionally slight swelling may appear, but in 
most instances there are no external signs, although the affected 
articulation is usually sensitive to deep pressure at all times. 

The more comprehensive term, anterior metatarsalgia, a term 
suggested by Poulosson, of Lyons, in 1889, may be employed to 
include Morton's neuralgia, and similar symptoms of pain and 
discomfort about the anterior metatarsal arch. For in many 
instances the cramp-like pain is referred to other points, for 

1 T. G. Morton, American Journal of the Medical Sciences, August, 1876. 
46 



722 ORTHOPEDIC SURGERY 

example, to several adjoining joints, or the discomfort caused 
apparently by direct pressure on the bones of the weakened arch 
may be more disabling than the irregular attacks of neuralgic 
pain characteristic of Morton's affection. 

Etiology and Pathology. — In 78 cases of anterior metatarsalgia 
in which the location of the pain was noted, it was referred to 
the fourth metatarsophalangeal articulation in 60 ; to the third and 
fourth articulation in 6; to the second, third, and fourth in 6, 
and in but 6 was the fourth articulation free from pain. The 
pain is most often unilateral, or, if the second foot is affected, it 
is usually after a considerable interval. 

The affection is more common in females than in males. Of 
84 cases, 64 were in women and 20 were in men. 

Anterior metatarsalgia is not an affection of early life, the 
average age in the reported cases being more than thirty years. 
It is far more common in private than in hospital practice, and 
not infrequently the patients are of a distinctly nervous type. 
In many instances it is supposed to be a family inheritance. The 
affection is usually extremely chronic. Occasionally the symp- 
toms may cease spontaneously, and in such instances a particular 
pattern of shoe usually receives the credit of the cure. 

Morton considered the disability to be a painful affection of the 
plantar nerves due to compression or pinching by the adjoining 
fourth and fifth metatarsophalangeal articulations. This com- 
pression was explained by the anatomical construction of the foot — 
i. e., the mobility of the fifth metatarsal bone which allowed it 
to roll above and under the fourth, its relative shortness which 
allowed the head and base of the adjoining phalanx to be brought 
against the adjoining head and neck of the fourth bone, and, 
finally, by the peculiar distribution of the external plantar nerve 
between these bones that made it or its fibres more liable to injury. 
This natural mobility and thus the predisposition to compres- 
sion might be exaggerated by a sprain, or possibly by rupture of 
the transverse metatarsal ligament, or the pain might be induced 
by wearing tight shoes, but in many instances no cause could be 
assigned. On this theory Morton advocated excision of the 
head of the fourth metatarsal bone to remove the point of counter- 
pressure. This operation has been performed many times, but 
practically no pathological changes in the resected bone or in 
the surrounding parts have ever been discovered. 

In more recent years the true significance of Morton's neuralgia 
and of similar pains in the front of the foot has been made more 



DISABILITIES AND DEFORMITIES OF THE FOOT 723 

clear by the study of the relation of weakness of the anterior 
transverse metatarsal arch to the symptoms. Attention was 
first called to this point by Poulosson, and again by Roughton, 
Woodruff, and others, and in a much more thorough and con- 
vincing manner by Goldthwait, 1 in 1894. 

The Anterior Metatarsal Arch.— In the normal foot the two 
central metatarsal bones, the second and third, are slightly longer 
and on a higher plane than their fellows. On the sole of the foot 
the arch is shown by the depression on the outer side of the 
muscular projection of the great toe-joint. When weight is borne 
all the metatarsal bones are on the same plane and the arch is 
obliterated, but when the weight is removed the arch is restored 
by certain natural resiliency. In walking and standing the weight 
falls in the neighborhood of the head of the third metatarsal 
bone, as shown by a thickening of the skin beneath it, but 
the strain on the metatarsal arch is relieved somewhat by 
the balancing action of the muscles about the first and fifth meta- 
tarsal bones, the inner and outer supports of the arch, and by 
the active assistance of the toes themselves. When the arch is 
weak or broken down this natural resiliency is lost, and, in some 
instances, the centre of the forefoot is not only depressed but it is 
fixed in this abnormal attitude. 

In the ordinary type of depressed anterior arch the deformity 
may be shown by an imprint of the foot, in which the flabby 
tissues of the depressed arch encroach upon the clear space repre- 
senting the longitudinal arch, and obliterate what Goldthwait 
calls the re-entering angle to the outer side of the great toe-joint, 
which in the normal foot indicates the highest point of the 
metatarsal arch. In many instances, however, the imprint of the 
foot subject to Morton's neuralgia may be to all intents normal, 
and, on the other hand, depression of the metatarsal arch, one of 
the very common results of improper shoes, may be present, yet 
unaccompanied by pain or discomfort. 

Depression of the anterior arch predisposes to pain because 
of abnormal pressure upon the persistently depressed articula- 
tions from beneath, and it predisposes to pain, as the writer 
has endeavored 2 to explain, because the metatarsophalangeal joints 
of an habitually depressed arch are exposed to the direct lateral 
compression of a narrow or ill-shaped shoe. 

This point may be illustrated in the hand. When lateral 

1 Boston Medical and Surgical Journal, vol. cxxxi. p. 233. 
- New York Medical Record, August 6, 1898. 



724 ORTHOPEDIC SURGERY 

pressure is applied, the hand is folded together and the anterior 
metacarpal arch is increased in depth, but if the fingers are dorsi- 
flexed so that it is fixed in a depressed position, then lateral 
compression causes great pain at all the articulations (Fig. 464); 
or if one finger is dorsiflexed and the corresponding metacarpal 
bone is thus forced below the level of its fellows, lateral compres- 
sion causes pain at the compressed joint. Or if the metacarpal 
bone of the little finger is made to over-ride the fourth, lateral 
pressure causes pain usually of a more acute character than at 
the other joints, because the opportunity for direct pressure is 
more favorable. 1 Finally, if firm pressure is made upon one or 
the other side of the head of the depressed metacarpal bone of the 




Position of the fingers corresponding to dorsiflexion of the toes, an attitude in 
which lateral pressure causes pain. 

dorsiflexed finger in the palm of the hand, a point of sensitive- 
ness, representing apparently the digital nerve, can be made out. 
The same experiments may be tried upon the foot with the same 
results, and it would seen to make clear the mechanism of the 
pain of Morton's neuralgia and the allied forms of discomfort at 
the front of the foot. 

Anterior metatarsalgia is in most instances the result of weak- 
ness or depression of the anterior metatarsal arch as a whole or in 
part, and the quality of the pain corresponds fairly to the form 
of 'weakness or deformity. If, for example, the entire arch 
is rigidly depressed, as in certain rheumatic affections, the 
discomfort is likely to be caused, in great degree, by the direct 

1 This anatomical peculiarity is well known to school-boys. 



DISABILITIES AND DEFORMITIES OF THE FOOT 725 

pressure of the sensitive depressed metatarsophalangeal joints on 
the sole of the shoe; or, if lateral pressure is exerted as well, the 
discomfort or pain may be referred to the metatarsal arch in 
general. If the metatarsal arch is weakened, depressed, and 
broadened, but not rigid, the discomfort is often referred, as in 
the preceding instance, to the centre of the arch, and this dis- 
comfort is increased, in some instances, by a painful callus repre- 
senting abnormal pressure at this point. If one of the metatarsal 
bones falls below its fellows, the lateral pressure of a narrow 
shoe may cause neuralgic pain at this joint, but in many cases 
in which the anterior arch is depressed the patient makes but 
little complaint of pain. In certain instances, more particularly 
those of Morton's typical neuralgia, the foot may appear to all 
intents normal; in such cases it may be inferred that the sharp 
and characteristic pain is caused by pressure applied to the over- 
riding fifth metatarsal bone, just as similar pain is felt if the hand 
is suddenly compressed while the fifth metacarpal bone is in the 
same position. This theory is the more probable when one con- 
siders the symptoms; for example, the sensation of something 
slipping or moving, the necessity for the removal of the shoe to 
flex and extend the toes and to compress the foot, apparently 
with the instinctive aim of replacing a depressed arch, or a mis- 
placed bone in the arch. It would also explain how the shoe 
may be the most direct of the exciting causes of the deformity, 
in that it compresses the forefoot and throws more weight upon 
it by elevating the heel. If the arch is depressed or becomes 
depressed, or if a bone in the arch overrides another, this compres- 
sion causes the symptoms. 

That classical Morton's neuralgia is but one expression of 
weakness of the anterior arch of the foot is illustrated by an 
analysis of 30 cases seen recently in private practice: 

Cases. 

The pain was referred to the fourth toe in 12 

third and fourth toes in 4 

" second, third, and fourth toes in . . 2 

third toe in 3 

" second and third toes in 2 

' second toe in 6 

" to all the toes in 1 

The right foot was involved in .13 

The left " " 7 

Both feet were affected in 8 

Twenty-four of the patients were females; four were males. 

The Influence of the Shoe in Causing Disability and Pain. — 
In the etiology of pain and discomfort about the anterior arch one 
must recognize the shoe not only as the direct cause of the pain, 



726 ORTHOPEDIC SURGERY. 

but also as the most important of the predisposing causes of 
weakness of the anterior arch, of which the pain is a symptom, 
since it compresses the toes, lifts them off the ground by its " rocker 
sole," and thus, by preventing their normal function, throws 
additional strain and pressure upon the arch. In fact, in a very 
large proportion of feet that are supposed to be normal in appear- 
ance and functional ability, the toes are habitually dorsiflexed 
in a claw-like attitude, that shows entire disuse of their function 
both as to support and progression. Women wear shoes with 
narrower soles and higher heels than men, and this seems the 
most reasonable explanation of the fact that they are more sub- 
ject to the affection. 

The shoe also predisposes to habitual elevation of the fifth 
metatarsal bone, because this bone almost invariably overhangs 
the narrow sole. The fourth metatarsal bone becomes, therefore, 
the outer support of the arch, and is almost always found to be 
on a lower level than the adjoining bones. This relation, together 
with a laxity of muscular and ligamentous support induced by 
injury or otherwise, may account for the location of the pain at 
this point in the majority of cases. Although in certain instances 
local neuritis may result from repeated injury, it is a rather unusual 
complication. Nor is it likely that the peculiar distribution of the 
nerves at the fourth joint has any direct influence on the location 
of the pain, for the nerve supply of all the joints and all the 
toes is practically identical. 

Other Factors in the Etiology. — Besides the general effect of the 
shoe, and the influence of an inherited predisposition to the 
affection, which seems evident in certain cases, or of weakness 
or direct injury of the anterior arch, one recognizes among 
the causes or complications of anterior metatarsalgia weak- 
ness of the longitudinal arch, which may be combined with a 
depression of the anterior arch. Less often the longitudinal 
arch may be exaggerated in depth and the dorsal flexion of the 
foot may be limited by a shortened tendo Achillis; thus more 
pressure is brought upon the front of the foot. In these cases 
the pain may be increased by corns or calloused skin beneath the 
depressed bones, and in many instances the discomfort of the 
depressed arch of the ordinary type is, in great part, caused by 
a sensitive corn or fibroma at the point of greatest depression, 
and the patient may be entirely relieved by its removal. (See 
Contracted Foot.) 

Although the symptoms of anterior metatarsalgia may be 



DISABILITIES AND DEFORMITIES OF THE FOOT 727 



Fig. 465 



explained in most instances by the primary effect of improper 
shoes, by weakness and abnormality of the foot itself, and by the 
local sensitiveness of the parts that are continually subjected to 
strain, pressure, and injury, yet in some instances the symptoms 
can be accounted for only by local neuritis; in others they are 
aggravated by gout or rheumatism or general debility, and, as 
has been mentioned in a large proportion of the cases, the patients 
are of a distinctly nervous type. 

It may be stated, in conclusion, that anterior metatarsalgia in 
its milder forms is a very common affection, and one rarely treats 
a patient who does not know of other cases similar to his own. 

Treatment. — The most important local treatment is to provide 
the patient with a suitable shoe. This shoe must be of proper 
shape with a thick sole, so broad that no 
lateral compression of the toes is possible, 
with a high arch, as suggested by Gibney, 
in order to remove a part of the pressure 
from the heads of the metatarsal bones, 
and a low heel. 

As an immediate treatment a firm bandage 
about the metatarsal region, as suggested by 
Morton, may aid in supporting the meta- 
tarsal arch, or, better, adhesive plaster strap- 
ping may be applied about the entire meta- 
tarsus, with the object of compressing the 
foot somewhat as a tight glove compresses 
the hand. Beneath or slightly behind the 
affected joint or the depressed arch, a pad, 
preferably an oval piece of sole-leather, about 
one inch by three-quarters of an inch in size 
and one-quarter in thickness, with bevelled 
edges, may be fixed to the sole of the foot 
with adhesive plaster, so that depression of 
the arch or over-riding of the adjoining 
bones may be prevented. This pad, sug- 
gested by Poulosson and Goldthwait, usually relieves the pain, 
and when the exact place has been ascertained it may be fixed 
to the sole of the shoe. 

As a rule, however, a metal support will be found to be more 
comfortable and far more efficient. This may be constructed of 
light steel (19 gauge) upon a plaster cast of the sole of the foot, 
of which the natural depressions, indicating the anterior and the 




A brace for anterior meta 
tarsalgia. A indicates a 
point beneath the fourth 
metatarsophalangeal artic- 
ulation, which is elevated 
in order to support the de- 
pressed articulation. 



728 ORTHOPEDIC SURGERY 

longitudinal arches, have been somewhat exaggerated. The 
anterior extremity of the brace is made as wide as the foot, and 
extends forward slightly beyond the metatarsophalangeal articu- 
lations. The brace serves to support the anterior as well as the 
longitudinal arch. In certain instances one or more of the 
metatarsophalangeal articulations may be sensitive to motion. 
In such cases the plate must extend from the heel to the 
extremity of the sole in order to splint the foot for a time. If 
there is slight depression of the longitudinal arch it may be 
further corrected by raising the inner border of the heel and 
sole of the shoe; but if it is more pronounced a flat-foot brace 
(Fig. 453) may be employed, whose anterior extremity is modified 
to support the metatarsal arch, as is shown in Fig. 465. If, on the 




Exercise for the weakened metatarsal arch. 

other hand, the arch is exaggerated and if dorsal flexion is limited, 
treatment with the aim of relieving this deformity will be necessary, 
as described under "contracted foot." When the immediate 
symptoms of pain and local discomfort have been relieved, the 
patient must endeavor to strengthen the natural supports of the 
arch by proper functional use of the foot, and by regular exercises 
of the muscles, more especially by methodical forced flexion 
of the toes, as this motion elevates the anterior metatarsal arch 
(Fig. 466). Massage of the foot and forcible manipulation of 
the toes for the purpose of overcoming restriction of motion are 
of special value. 

If the depressed anterior arch is rigid, as in some instances, 
its flexibility must be restored by manipulation * or by forcible 
correction under anaesthesia before a brace can be applied. If 



DISABILITIES AND DEFORMITIES OF THE FOOT 729 

the symptoms are very acute, and particularly if they have fol- 
lowed direct injury, the parts should be placed at rest and the 
anterior arch should be elevated and supported by a properly 
applied plaster bandage. 

In chronic and resistant cases or when conservative treatment 
cannot be applied, resection of the neck and head of the meta- 
tarsal bone at the seat of pain may be performed as advocated by 
Morton. The operation is very simple. An incision is made 
over the dorsal surface of the joint, and the bone is divided by 
bone forceps. The toe is not, as a rule, removed, but after the 
operation it slowly recedes between the adjoining metatarso- 
phalangeal joints, causing a rather noticeable deformity. The 
operation is, as a rule, successful, but in the majority of cases it 
is unnecessary. 

The general condition of the patient should, of course, receive 
attention, and local applications, electricity, and the like, may 
be of benefit in special cases. 

A sensitive callus beneath the arch may require treatment, and in 
certain cases its removal may be the only treatment required other 
than an improved shoe. But, as a rule, the cause of the callus 
is habitual depression of one or more of the metatarsophalangeal 
articulations, so that cure can only be assured by supporting 
the arch and by strengthening its natural supports. If as in cer- 
tain instances the depressed joint cannot be replaced in normal 
position the head of the metatarsal bone must be removed. 

Woodruff 1 described a case of what he called "incomplete luxa- 
tion of the metatarsophalangeal articulation," in which the symp- 
toms, practically identical with those of Morton's neuralgia, 
are ascribed to an upward displacement of the proximal phalanx 
at the fourth metatarsophalangeal joint. 

It may be stated in this connection that in the ordinary forms of 
metatarsalgia patients often refer the pain and local sensitiveness 
to the anterior extremity of the metatarsal bone rather than to its 
lateral aspect. Persistent dorsal flexion of the toes that is so 
commonly associated with depression of the arch may strain the 
capsular ligament, -and, subjecting this portion of the joint to 
abnormal pressure, may explain the location of the pain. But 
except in extreme cases it can hardly be classed as a sublux- 
ation. 

Another writer, Guthrie, 2 described a case in which intense 

1 New York Medical Record, January 18, 1887. 

2 Lancet, March 19, 1892. 



730 ORTHOPEDIC SUBGEBY 

pain followed overextension of the third phalanx upon the second. 
Such cases are extremely uncommon, and need only be mentioned. 

Achillobursitis. 

Synonyms. — Achillodynia, achillobursitis anterior, retro- 
calcaneobursitis. 

Under the title of Achillodynia, Albert, 1 in 1893, called par- 
ticular attention to an affection characterized by pain and sen- 
sitiveness about the insertion of the tendo Achillis, symptoms 
usually caused by irritation or inflammation of the small bursa 
lying between the insertion of the tendon and the bone (Fig. 467). 
Etiology. — In the acute cases the cause of the bursitis often 
appears to be a strain of the tendon or direct injury, as the symp- 
toms appear immediately after running or jumping or after a 
fall, sometimes after a long walk or bicycle ride. 

In the subacute cases the symptoms may begin almost imper- 
ceptibly, so that it may be impossible to assign a direct cause 
other than the pressure of the shoe, aggra- 
vated, it may be, by an exostosis of the os 
calcis beneath the insertion of the tendon 
or by concretions within the bursa. In 
many instances rheumatism, gout, gonor- 
rhoea, or one of the infectious diseases 
appear to be associated, directly or in- 
directly, with the onset of the symptoms, 
or the bursa may be secondarily involved 
in tuberculous disease of the os calcis. 

Symptoms. — In a typical case pain is 
felt in the back of the heel at the insertion 
Bursa between the tendo f ^ e tendon; the pain is increased by use 

Achillis and the os calcis. \ ," 

of the foot, and particularly by the attitudes 
in which the strain on the part is increased, as, for example, in 
descending stairs. There is also sensitiveness to pressure about 
the back of the heel on either side of the insertion of the tendon. 
In most cases a slight swelling, often more prominent on the inner 
than the outer side of the tendon, indicates the situation of the bursa. 
In the chronic cases the enlargement of the bursa is very- 
noticeable, and, in addition, the entire posterior aspect of the heel 
often appears to be thickened. This is due probably to the 
secondary irritation about the fibrous expansion of the tendon 

1 Wiener med. Presse, January^, 1893. 




DISABILITIES AND DEFORMITIES OF THE FOOT 731 

and the adjoining periosteum. In many cases the symptoms are 
pronounced ; pain is often felt in the bottom of the heel or it radiates 
up the back of the leg. The patient, unable to use the power 
of the calf muscle, everts the foot in walking, thus subjecting 
the arch to overstrain, so that the symptoms of the weak foot 
are often added to those of the original trouble. Not infre- 
quently, however, the two affections may be associated from the 
beginning in one or the other foot. The patient complains much 
of stiffness and weakness at the ankle and subastragaloid joints. 
In acute cases, or in acute exacerbations, there is usually burn- 
ing and throbbing pain characteristic of inflammation, but in the 
subacute form the pain is slight, and is troublesome only after 
overexertion. 

Pathology. — The pathological changes do not differ from those 
found in and about other bursa? under similar conditions. In 
the mild cases the lining membrane is simply congested, and the 
cavity contains serous fluid. In the chronic cases the walls are 
much thickened, 1 the lining membrane is fringed and redupli- 
cated; the contents are semisolid, and sometimes calcareous 
masses are present. Similar changes are found, however, in the 
bursa? of apparently normal subjects, so that the condition of the 
bursa may not always correspond to the character of the symp- 
toms. Suppuration of the sac occasionally occurs, and it may be 
the seat of tuberculous or syphilitic disease. In cases of long 
standing the parts adjoining the bursa, the expansion of the 
tendon, and the periosteum become thickened, so that the bone 
appears to be increased in breadth and may actually become so. 

Treatment. — When once established the affection is usually 
of a very chronic nature, as is explained by the strain to which 
the sensitive part is subjected by the use of the foot. It is, there- 
fore, important to apply efficient treatment at the beginning of 
the affection if an opportunity is afforded. Efficient treatment 
implies absolute rest, and in all cases of any severity, particularly 
those of acute onset, a well-fitting plaster bandage should be 
applied to hold the foot slightly inverted and at a right angle to 
the leg. This should be worn until all symptoms have subsided. 
In very mild cases, following immediately on a strain or overuse, 
simple rest with the application of heat, massage, and pressure 
may be efficient. And in the subacute cases the symptoms may 
be relieved by the application of a long, broad band of adhesive 
plaster, from the toes over the back of the heel to the upper 

1 Rossler, Deut. Zeit. f. Chir.,'Bd. brii.,'H. 1 and 3. 



732 OB THOPEDIC 8 UB QEB Y 

third of the calf, the foot being slightly plantar flexed. This is 
firmly fixed by narrow strips of plaster about the metatarsus, 
the heel, and the calf. By this means pressure is exerted upon 
the bursa, and much of the strain is removed from the tendon. 

In persistent cases a brace may be used with advantage for 
the purpose of preventing strain upon the tendon. Two lateral 
uprights with a calf band and padded strap that crosses the upper 
third of the leg are attached to the shoe, provided with a stop 
joint at the ankle as used in the treatment of paralytic calcaneus to 
prevent dorsal flexion. (See Talipes.) As the patient is usually 
sensitive to jar, the heel of the shoe should be replaced by one 
of thick rubber. In connection with the brace the stimulation 
of the cautery and the pressure of the adhesive plaster strapping 
seem to hasten the absorption of the effusion in and about the 
bursa. If weakness or depression of the arch is present, as a 
result of the disability or combined with it, a foot-plate should 
be applied, and general affections, with which the disability is 
sometimes associated, should, of course, receive attention. 

Operative Treatment. — In persistent cases, in which the symp- 
toms are not relieved by treatment, the enlarged bursa should be 
removed by an incision on the inner side of the tendon, as the 
swelling is usually most prominent here. A plaster bandage is 
then applied and is continued until the symptoms have subsided. 
If the case is a chronic one, it may be advisable to divide the 
tendo Achillis in order to completely remove for a time the strain 
upon the sensitive part. A brace of the character already de- 
scribed may be used with advantage for a time after the plaster 
support has been removed. Operative treatment is, of course, 
indicated in acute suppurative inflammation, in tuberculous dis- 
ease, or if an exostosis beneath the bursa or concretions within 
the sac are present, as shown by an x-ray negative. 

Achillobursitis Posterior. 

Tenderness, pain, and swelling at the back of the heel may 
be due to inflammation of the small superficial bursa that lies 
between the tendon and the skin. The cause is usually injury 
or the pressure of the shoe. The symptoms resemble somewhat 
those of achillobursitis anterior, but the swelling is more super- 
ficial, and the pain is caused by direct pressure rather than by 
tension on the tendo Achillis. In the ordinary case removal of 
the pressure will at once relieve the symptoms, but if the discom* 



DISABILITIES AND DEFORMITIES OF THE FOOT 733 

fort is considerable a plaster bandage may be worn for a week or 
more. 

Sensitive points at the back of the heel are usually caused by 
the pressure of the shoe. In rare instances prominent points or 
exostoses of the os calcis are present, that may require special 
protection or removal. 

Strain of the Tendo Achillis. 

Not infrequently, and usually as the result of strain or overuse 
of the foot, patients complain of symptoms similar to those of 
achillobursitis, but on examination one finds that the pain and 
sensitiveness are referred to the tendon itself. There is no swell- 
ing at its insertion, or pain on lateral pressure on the os calcis. 
The sensitive area may be as high up as the junction of the 
tendon with the muscle, and, again, the midpoint of the tendon 
seems most painful. 

The cause in some cases may be a direct strain of the tendon 
or of the muscular fibres near its origin, or inflammation of its 
fibrous covering due probably to the same cause. The treatment 
is similar to that of the milder type of achillobursitis, by the 
adhesive plaster strapping, by rest, and, later, by massage. 
Recovery is usually rapid. 

Painful Heel— Calcaneobursitis. 

Pain referred to the bottom of the heel and sensitiveness to 
pressure on standing are common symptoms of the weak or flat- 
foot. Pain at this point may be one of the symptoms of achillo- 
bursitis also. In rare instances the painful point is clearly 
localized, and is confined to a small area in the neighborhood of 
the inner tuberosity of the os calcis. The cause of the symptoms 
in such cases may be an inflamed bursa lying between the perios- 
teum and the fatty tissue of the heel. Such bursse may contain 
hard substances or even a fasciculated neuroma. 1 

Similar symptoms may be induced by exostoses. Several of 
these cases have been reported recently by Baer, 2 in which the 
exostoses followed gonorrhoea, apparently beginning in the 
musculo periosteal attachment of the flexor brevis digitorum. 

More general pain and sensitiveness referred to the heel are often 

1 Brousses et Bert.hier, Revue de Chir., August, 1895. 

2 Surgery, Gynecology, and Obstetrics, July 2. 1906. 



734 OB THOPEDIC SURGERY 

the result of direct pressure and bruising of the tissues incidental 
to overuse of the feet. 

Treatment. — Treatment must be directed to the condition of 
which the pain is a symptom, and, as has been stated, it is most 
often one of the symptoms of the weak or broken-down arch. 
If the sensitive point is localized, and if the pain is increased by 
jars, a thick rubber heel combined with an inner sole, so cut out 
as to remove the direct pressure on the sensitive point, will often 
relieve the symptoms. In persistent cases, in which the sensitive 
point is distinctly localized, operative intervention for the removal 
of the bursa or exostoses is indicated. 

Sensitiveness due to direct contusion, or bruising of the tissues 
caused by overuse, must be treated by rest and by change of 
occupation, unless reduction of the body weight or improve- 
ment in attitudes and local support relieve the symptoms. 

Plantar Neuralgia. 

Synonym. — Plantalgia. 

Pain referred to the sole of the foot and sensitiveness to pressure 
on the plantar fascia are usually symptomatic of the contracted 
foot (cavus); less often such symptoms accompany the weak or 
broken-down arch. 

Pain, tenderness, and thickening of the fascia sometimes follow 
injury (rupture of the fascia), 1 and a similar condition has been 
described by Franke as one of the sequelae of influenza. 2 It 
may be present, also, in the patients who suffer from gout or 
rheumatism. 

Treatment. — Pain in the sole of the foot, symptomatic of the 
contracted or of the weak foot, may be relieved by the treatment 
of the conditions of which it is a symptom. In the rare instances 
in which the fascia is itself injured or diseased, local rest, as 
afforded by the plaster bandage, is indicated until the acute 
symptoms have subsided. 

Erythromelalgia. 

Weir Mitchell 3 has described a series of cases characterized by 
attacks of heat, redness, pain, and often swelling, most marked 

i Lederhose, Verhand. der Deut. G. f. Chir., XXIII. Kong., 1894. 

- Archiv f. klin. Chir., 1895, Bd. xlix. 

3 American Journal of the Medical Sciences, 1878, vol. lxxvi. 



DISABILITIES AND DEFORMITIES OF THE FOOT 735 

about the soles of the feet. Of 27 cases all but 2 were in women, 
many of whom were of a nervous or neurasthenic type. The 
affection appears to be a form of vasomotor disturbance. Disturb- 
ances of the circulation and burning pain in the soles of the feet 
are common symptoms of the weak foot and of allied affections, 
but in such cases there is not the flushing and swelling character- 
istic of erythromelalgia. In this affection the circulatory disturb- 
ances are not, as a rule, confined to the feet, but are seen in the 
legs and even in the upper extremities. 1 It deserves mention as 
a possible explanation of symptoms in obscure cases. 2 

Dysbasia Angio Sclerotica: 3 Intermittent Limp. 

The title indicates a sclerotic change in the bloodvessels by 
which the nutrition of the foot is impaired. The symptoms are 
discomfort in the feet and legs. The patient, comfortable when 
at rest, after walking may begin to limp, or on standing to suffer 
from stiffness, numbness, and pain. On examination one often 
notes that the feet are cyanotic or of a dark-red color, and that 
the circulation is impaired. In more advanced cases the sclerotic 
changes in the arteries are apparent on palpation and this may be 
demonstrated in certain instances by x-ray pictures. Reynaud's 
disease represents a more advanced type of the affection. It is 
described because it is often mistaken for the symptoms of 
flat-foot. In my own experience the patients have been adult 
male Jews. 

The treatment aside from massage and the like is to adapt 
the activity of the patient to his blood supply. 

Hallux Rigidus. 

Synonyms. — Hallux flexus, painful great toe. 

Hallux rigidus is a painful affection of the great toe-joint, 
characterized by restriction of motion, particularly of the range 
of dorsal flexion. In advanced cases the first phalanx may be 
slightly plantar flexed, together with its metatarsal bone; hence 
the name hallux flexus, applied by Davies-Colley, who first de- 
scribed the affection. 

The restriction of motion may be complete, as implied by the 
term rigidus; the joint appears unduly prominent or enlarged, 

1 Kahane, Klin, therap. Wochen., May 20, 1900. 

- Prentiss, Transactions of the Association of American Physicians, 1897, vol. xii. p. 303. 

* Erb, Munch, med. Wocb.. 1904, No. 2. 



736 



ORTHOPEDIC S UR GER Y 



usually slightly congested, and pressure or forced movement 
causes pain. 

The symptoms of which the patient complains are a burning 
or throbbing pain in the joint, increased by standing, and partic- 
ularly by walking, because of the enforced movement of the 
stiff and painful articulation. There are many cases in which 
there is no actual deformity of the joint or other noticeable change; 
the restriction of motion is much less, and the symptoms are corre- 
spondingly slight. 

Etiology. — Typical hallux rigidus is most common in adoles- 
cence, and it is very often associated with the weak or broken- 
down foot. In such cases the toe is forced 
into the narrow part of the shoe, and is thus 
subjected to lateral and to longitudinal pressure, 
as well as to the additional strain that the atti- 
tude, characteristic of the weak foot, throws upon 
it. In some cases the habitual plantar flexion of 
the toe may be the result of an instinctive effort 
to support the weak arch (hammer-toe flat-foot — 
Nicoladoni). In other instances hallux rigidus 
is caused directly by traumatism, as by stubbing 
the toe, by kicking a hard object, or by other 
form of strain or injury. The affection appears 
to be, primarily, a form of periarthritis, caused 
by injury or pressure. The restriction of motion 
is in part due to muscular spasm, and in part 
to the irritative and accommodative changes in 
the ligaments and tendons. In more advanced cases changes in the 
cartilage and shape of the articulating surfaces, due to disuse of 
function and to pressure and friction, may be present. 

Treatment. — If the rigid and painful joint is not associated 
with a weak arch, it may be relieved by providing the patient 
with a proper shoe which exerts no pressure on the sensitive part. 
Motion of the joint may be lessened by increasing the thickness 
of the sole, or, if necessary, it may be entirely restricted by the 
insertion of a brace of tempered steel between the two layers of 
the sole, as shown in the diagram. If, as in some instances, the 
flexed and painful toe is associated with rigid flat-foot, both 
deformities may be overcorrected, under anaesthesia, and retained 
in proper position by a plaster bandage, as a preliminary treatment. 
If the milder type of painful joint is associated with the ordi- 
nary weak foot, the treatment of the latter condition will usually 




The dotted outline 
shows the shape of 
the steel splint that 
may be inserted in 
the sole of the shoe 
for hallux rigidus. 



DISABILITIES AND DEFORMITIES OF THE FOOT 737 

relieve the symptoms. In this class, particularly among the 
poorer patients, the shoe may be raised on the inner side and 
the sole stiffened by means of the wedge-shaped sole, as already 
described in the treatment of the weak and flat-foot. If painful 
motion is restricted, and if the exciting causes of the disability 
are removed, relief of the symptoms is usually immediate. In 
the chronic cases, in which the pathological changes are more 
advanced, excision of the joint may be necessary. 

Painful Great Toe-joint in Older Subjects. 

A similar condition of the joint is sometimes found in older 
subjects. In many instances the foot is well-formed, and the 




Hallux rigich 



and flat-foot, showing the persistent flexion of the toe on the 
metatarsal bone. 



restriction of motion in the joint is very slight; yet forced dorsal 
flexion causes pain, and long standing or walking induces dis- 
comfort, particularly a dull ache in the joint and sharp neuralgic 
pain referred to the terminal phalanx. In some cases the onset 
of the symptoms may be ascribed to a long walk or "mountain 
climb," in others to wearing tight shoes, and in some instances 
no definite cause can be assigned by the patient. In cases of 
this type the symptoms are often supposed to be evidences of 

47 



738 



ORTHOPEDIC SURGERY 



gout or rheumatism and in certain instances there is a distinct 
hypertrophic change corresponding to Heberden's nodes on the 
fingers. Although in certain instances the discomfort may be 
aggravated by a constitutional disease, still no relief can be obtained 
by medication unless it is combined with the local treatment 
that has been described in the preceding section. The relief 
afforded by such treatment alone proves, in many instances, that 
the affection is purely local in its character (Fig. 469). 

As has been mentioned, pain referred to this joint is a common 
symptom of the weak foot and of the contracted foot as well. It 
is also caused by simple pressure on the joint, and by the use of 
improper shoes which "force the toes into the abducted position. 




Simple congenital 



adduction without inversion — a form of pigeon-toe. 



In rare instances pain directly beneath the great toe and sensi- 
tiveness to pressure about the sesamoid bones seem to indicate an 
inflammation of the tendon sheath or local periarthritis. If the 
discomfort is persistent the sesamoid bones may be removed. As 
a rule, such symptoms occur only in combination with pain or 
deformity of the great toe-joint. If the joint is disorganized 
from arthritis, excision may be advisable. 



Hallux Varus. 

Adduction of the great toe is not infrequent in infancy, and it may 
be associated with a slight degree of varus deformity (Fig. 470) . 



DISABILITIES AND DEFORMITIES OF THE FOOT 739 



Fig. 471 



The peculiarity attracts the mother's attention because ^of the 
difficulty of drawing on the socks. In many instances the muscles 
seem abnormally developed, and the toe appears to be somewhat 
prehensile in its movements. 

Treatment. — The abnormal mobility may be checked by en- 
closing the toes with a narrow strip of adhesive plaster; in any 
event, the ordinary shoe may be de- 
pended upon to correct any residual 
deformity of this character. If the 
adducted toe is combined with varus, 
it represents a slight degree of club- 
foot that must be corrected in the 
ordinary manner. (See Talipes.) 

Pigeon-toe. 

Congenital hallux varus forms one 
variety of what is known as pigeon-toe 
or the habitual turning in of the feet 
in walking. The inward rotation may 
be due also to bow-legs, or it may be 
an effect of congenital talipes that 
persists after the cure of the defor- 
mity, or of the exceptional variety of 
coxa vara in which the depressed 
necks of the femora are turned for- 
ward. In most instances pigeon-toe 
in childhood is symptomatic of weak- 
ness either of the arch of the foot or 
of the knees (genu valgum). In such 
cases it is a conservative effort of 
nature that serves to check further 
deformity, and it needs no treatment 
other than that which may be applied 
to the weakness of which it is a 




symptom. 



An appliance constructed of leather 
bands and elastic webbing for the 
In the exceptional Cases, in which correction of in-toeing. Name of the 
. , „ inventor unknown. 

the posture is not symptomatic ot 

weakness or the effect of deformity, the sole of the shoe may 
be raised slightly on the outer border. This will correct the 
attitude in the milder type, if combined with instruction and 
training. In rare instances the in-toeing seems to be caused by 



740 OR THOPEDIC S UB GEB Y 

limitation of the range of outward rotation at the hip-joints, a 
restriction that must be overcome by systematic stretching of 
the contracted parts. In these and in the more obstinate cases 
of the simple type apparatus may be applied, similar to that 
used in the after-treatment of congenital club-foot, to hold the 
feet in the proper attitude (Fig. 471). It must be borne in mind 
that the proper attitude of the feet is one of parallelism not of 
outward rotation, and that slight pigeon-toe will, as a rule, correct 
itself as the child grows older. 

Metatarsus Varus. 

This is a deformity in which the metatarsus is adducted on 
the tarsal bones. It may be congenital as an accompaniment of 
talipes varus, it may be a compensatory effect of valgus deformity 
or knock-knee. Varus deformity of the first metatarsal bone is a 
constant accompaniment of hallux valgus. 

Hallux Valgus. 

Hallux valgus is a deformity in which the great toe is turned 
outward to an exaggerated degree. Outward deviation of the toe 
is so common, owing to the use of improper shoes, that it is not 
recognized as a deformity, at least from the popular standpoint, 
unless the joint appears to be much "enlarged," forming a so-called 
bunion. 

Hallux valgus is practically a partial dislocation of the phalanx 
upon the metatarsal bone. In well-marked cases the metatarsal 
bone is adducted or turned inward, so that an abnormal interval 
separates its head from its fellows, while the phalanx is displaced 
outward and articulates only with the outer condyle. The angle 
thus formed, or, more properly, the inner condyle of the adducted 
metatarsal bone, makes the prominent or "outgrown" joint (Fig. 
481). This projects sharply beneath the skin, and is exposed to 
injury and to the pressure of the shoe; thus a bursa develops 
beneath the skin, while a corn or callus forms on its superficial 
surface. The projecting bone, covered by the irritated bursa and 
the thickened skin, makes up the bunion. 

In many instances the other toes are displaced outward, in 
the direction corresponding to that of the great toe, or this may 
be rotated on its long axis and lie above or beneath its fellows. 

Pathology. — The pathological changes are such as usually 
follow deformity, disuse of function, and injury. The cartilage 



DISABILITIES AND DEFORMITIES OF THE FOOT 741 

on the exposed condyle atrophies, the sesamoid bones, together 
with the tendon, are displaced outward, the tissues on the outer 
side undergo accommodative shortening, while those on the inner 
side are correspondingly lengthened and attenuated. The surface 
of the bone beneath the irritated periosteum is often roughened 
and irregular, and exostoses may form about the condyle, and 
thus aggravate the effects of the lateral pressure. 

Etiology.— The deformity is the direct effect of shoes that are 
too narrow and of improper shape, and in some instances too 
short for the foot, so that the great toe is subjected to lateral 
and longitudinal pressure. The deforming effect of the shoe is 
increased if the arch is weak, so that the toe is forced forward 
into the narrower part of the shoe when the foot is in use. The 
deformity may be increased by injury or by the changes that 
follow gout, rheumatism, rheumatoid arthritis and the like, and 
in rare instances the distortion may be the direct result of such 
diseases; but all other factors are of slight importance when 
compared to the deforming influence of the ordinary shoe. The 
deformity begins at a very early age; it advances more rapidly 
during adolescence, but the symptoms do not often become 
troublesome until later years. Both toes are affected, as a rule, 
although the deformity and its accompanying symptoms are 
usually more marked on one side. 

Symptoms. — As has been stated, the slighter grades of defor- 
mity are not recognized as such, and it is usually because of 
the pain due to the irritated corn or bursa, and incidentally 
because of the outgrown joint, that the patients apply for 
treatment. 

Treatment. — The symptoms in the ordinary cases may be 
relieved by providing a proper shoe, by which pressure on the 
joint is completely removed (Figs. 447 and 478). The sole 
should be strong, and it should be slightly thicker along the inner 
side, so that the sensitive joint may be inclined away from the 
upper leather. In cases in which the deformity is not far advanced 
the use of a suitable shoe that allows space for an improved position 
of the great toe, combined with methodical manual correction 
of the deformity and exercise of the disused muscles while the 
toe is guided in the proper directions by the fingers, will relieve 
the symptoms promptly and practically cure the deformity. If 
the longitudinal or the metatarsal arches are depressed they should 
be properly supported (Figs. 443 and 465). 

Several forms of correcting braces have been devised, to be 



742 ORTHOPEDIC SURGERY 

worn during the day, a digitated stocking and special shoe being, 
of course, necessary. 

A simple device for holding the toe in an improved position 
is the Holden toe-post, recommended by Walsham and Hughes. 
This is a thin piece of metal so fixed in the front and inner side 
of the sole of the shoe that it separates the first and second toes 
from one another and holds the former in an improved position. 
It, of course, necessitates a special shoe and a special shoemaker 
to fit it in its proper place. 

Sampson 1 makes the toe-post of tin and places it in a card- 
board inner sole, as illustrated in the diagrams (Figs. 472 to 475). 
The use of a splint at night is also of some service. For this 
purpose a piece of celluloid about one-eighth inch in thickness, one 
inch in width, and about six inches in length may be used. This, 
having been moulded to the proper contour by placing it in hot 
water, is secured by tapes to the inner side of the toe and foot. 

It may be stated that in the class of cases that can be success- 
fully treated by mechanical correction few patients will be found 
who are sufficiently interested in the cure of the deformity to 
submit to the slight discomfort that the wearing of even a 
carefully adjusted brace entails. 

Operative Treatment. — In cases in which the deformity is of 
long standing, and in which the projecting condyle or the exostoses 
make protection of the sensitive joint difficult, an operation is 
indicated. The primary object of the operation is to remove 
the projecting bone. This may be accomplished by a slightly 
curved incision about the inner aspect of the condyle, the centre 
being below the joint, so that the scar will not be subjected to 
pressure. The flap of skin is raised, the periosteum and part of 
the capsule are lifted from the bone, and the projecting bone is 
removed with a chisel, so that the surface is made perfectly 
smooth. Contracted tissues that resist a corrected position of 
the toe are stretched or divided, and the wound having been 
closed with sutures a plaster bandage is applied about the foot 
and toe. This may be worn with advantage for several weeks. 
The after-treatment consists in the use of a proper shoe and daily 
manual adduction of the toe, in order to retain the improved 
position. 

Cuneiform osteotomy of the metatarsal bone is an effective 
operation if the base of the wedge includes the projecting bone. 

1 Johns Hopkins Bulletin, January, 1902. 



DISABILITIES AND DEFORMITIES OF THE FOOT 743 

Resection of the head of the metatarsal bone is the most effective 
operation if the deformity is extreme. 

As has been stated hallux valgus is often combined with the 




Making the pattern for a toe-post. A heavy piece of paper folded once along the line A B, 
A D E and B C F axe cut away, leaving the tongue A D C B. AD should equal the depth 
of the shoe at that point, and A B should be as wide as the length of the slit in the card- 
board inner sole. The tongue is inserted in the slit, and the bases folded back and cut away 
to conform to the front of the inner sole. When removed and straightened out this forms 
the pattern in Fig. 473. 



H 



Fig. 


473 






A 


E 

— L \ 


/ % 




M 


1 c r 


B 


\ € 



Pattern of paper from which 

is folded along the dotted lines A B 



F T 

tin is cut. The edges D D and C C are to be turned in. Tin 



-D C and D C forming the toe-post in Fig. 474. 



Fig. 474 




Shows the toe-post ready to be inserted into the cardboard inner sole. Rough points on 
the upper and under surfaces of the base, which are made by punching holes with an awl, 
hold the toe-post to both the inner sole of the shoe and the cardboard inner sole. 




Cardboard inner sole with toe-post and foot adductor attached. (Sampson.) 



weak or broken-down arch; in such cases the foot must be sup- 
ported by a properly fitted brace. This is of special importance 
after treatment by operation. 



744 



OB THOPEDIC S UE GEB Y 



Bunion. — The discomfort of hallux valgus is caused in great 
part by the irritated bursa and the overlying callus. These symp- 
toms may be relieved by rest and by hot applications. After- 
ward the callus or corn may be removed, and the sensitive bursa 
may be protected by a bunion plaster. Operative treatment should 
be deferred until after the acute symptoms have subsided. 

Hammer-toe. 

Hammer-toe is a contraction of one of the toes, usually of the 
second, in which the first phalanx is dorsiflexed, the second plantar 
flexed, while the third may be flexed or extended. The con- 
tracted toe is overlapped by its fellows; its projecting dorsal 
surface is subjected to the pressure of the upper leather of the 
shoe, and the terminal phalanx, forced against the sole of the 




Hammer-toe, hallux valgus, and flat-foot. 

shoe and compressed by the adjoining toes, becomes flattened 
into a club or hammer-like form. The nail is distorted and 
often "ingrown;" in most cases a corn or callus forms upon the 
extremity of the toe, and a small bursa and corn over the pro- 
jecting knuckle on the dorsal surface. A third corn or callus is 
often found beneath the head of the metatarsal bone which has 
been forced downward by the flexion of the toe. 

Hammer-toe is usually bilateral; it may be congenital and 
even hereditary, but it is usually caused by shoes that are 
too short and too narrow. The second toe is deformed most 
often, because it is the longest and because it suffers most from 
the lateral compression as well. The deformity begins, as a rule, 
in early childhood, when, the growth of the foot being rapid, it 
is more likely to suffer from the effects of outgrown shoes, and 
socks as well. 



DISABILITIES AND DEFORMITIES OF THE FOOT 745 

Symptoms. — The symptoms are practically those of the corns 
or blisters caused by the pressure of the shoe, but they are often 
sufficiently troublesome to interfere seriously not only with the 
comfort, but with the ability of the patient. 

Treatment. — The resistance to the rectification of the deformity 
is caused by the accommodative changes that .follow habitual mal- 
position. In cases of long standing all the tissues may be involved 
in the contraction, of which the most resistant are the short- 
ened capsular and lateral ligaments of the first interphalangeal 
joint. 

The congenital hammer-toe of the infant may be treated by 
manipulation. When the resistance is overcome the toe may be 
held in proper position by narrow strips of adhesive plaster passed 
over and under it and about its fellows. In older children a 
digitation in the stocking will often hold the toe in place if the 
deformity is slight and if a wide shoe is worn. In adult cases, 
in addition to the manipulation and shoe, a retention apparatus, 
in the form of a light plantar splint, or stiffened inner sole to 
which the toe can be attached, should be - worn. If the deformity 
is more resistant the toe may be straightened by force, aided, if 
necessary, by the subcutaneous division of the contracted ligaments ; 
but in ordinary cases the only effective treatment is resection of 
the joint. Sufficient bone should be removed to permit the cor- 
rection of the deformity, or, in case of its recurrence, to prevent 
the projection of the joint above its fellows. A splint of celluloid 
or other material should be worn for a time. By this operation 
permanent relief may be assured, and it is to be preferred to the 
mutilation of amputation. 

Overlapping Toes. 

Overlapping toes are very common among adults, owing to the 
pressure of the narrow shoe; and not infrequently such deformity 
is seen in infancy of apparently congenital origin. Deflected or 
deformed toes may be treated in infancy by manipulation and by 
support with strips of adhesive plaster in the manner described. 

In childhood persistent manual correction and proper shoes 
will usually overcome acquired deformity. In older subjects an 
inner sole somewhat like a sandal, to which the toes may be 
attached by bands of tape, may be employed if the deformity 
is considered of sufficient importance by the patient to demand 
treatment. 



746 ORTHOPEDIC S UBQER Y 

Exostoses of the Foot. 

Simple exostoses of the foot, as distinct from those that are 
incidental to disease, as, for example, to osteoarthritis, are, in 
most instances, induced by pressure upon a projecting bone 
of a somewhat deformed foot. The common examples are the 
hypertrophy of the navicular (often seen in weak foot of young 
children), the projection of the cuneiform bones on the dorsum of 
the hollow or contracted foot, the enlargement of the internal 
condyle of the first metatarsal bone complicating hallux valgus, 
the exostoses on the posterior aspect of the os calcis in achillo- 
bursitis or those on its under surface that may be induced by, 
or that become sensitive to, pressure in cases of gonorrhceal infec- 
tion and the like. 

As a rule, the treatment of the deformity of the foot and the 
removal of pressure will relieve the symptoms without othei 
treatment. Operative removal is indicated when such treatment is 
not effective. 

Fracture of the Metatarsal Bones. 

Fracture of a metatarsal bone, most often the second or the 
fifth, may occur without apparent cause other than walking. 
The pain and the subsequent swelling in such cases may be inex- 
plicable until the diagnosis is made clear by an a;-ray picture. 

Displacement of the Peronei Tendons. 

Permanent displacement of these tendons forward of the mal- 
leolus is not uncommon as a result of paralytic deformity, par- 
ticularly talipes calcaneus, and in such instances it gives rise to 
no symptoms. Displacement of one or both of the tendons, or 
rather a laxity of their attachments that allows an occasional 
displacement or slipping from the groove behind the malleolus, 
may result in serious disability, because of the pain that follows 
the displacement and because of the weakness and insecurity of 
which the patient usually complains. 

The cause of the laxity of the tissues that allows displacement 
in feet otherwise normal may have been injury, but as the affec- 
tion is often bilateral, the predisposition may be congenital. 

Treatment. — If the displacement is recent, as when it follows 
injury, the tendons should be replaced, and the foot should be 
fixed in a plaster bandage until repair has taken place. If, as 



DISABILITIES AND DEFORMITIES OF THE FOOT 747 

in certain instances, dorsal flexion is limited, the restriction should 
be overcome before the bandage is applied. If the displacement 
is habitual, a brace may be applied to restrain those motions 
at the ankle that induce it. In the chronic cases an operation 
with the aim of fixing the tendons by deepening the groove in 
the malleolus, or by suturing the displaced sheath in its normal 
position, may be indicated. If on examination the cause of the 
displacement appears to be a shortening of the tendon it may 
be divided and lengthened in the ordinary manner. 

Shoes. 

The shoe as a factor in the etiology of deformity and disability 
has been mentioned several times in the preceding pages, but it 
is a subject of such importance that it deserves especial consider- 
ation. 

The object of the shoe is to cover and protect the foot ; therefore, 
the one should correspond to the shape of the other. If the feet 
are placed side by side the outline and the imprint of the soles 
will correspond to the accompanying diagram (Fig. 477). The 
outline demonstrates the actual size and shape of the apposed 
feet, emphasized by enclosing them in straight lines. Thus, each 
foot appears to be somewhat triangular, being broad at the front 
and narrow at the heel. The imprint shows the area of bearing 
surface, and owing to the fact that but a small portion of the arched 
part of the foot rests upon the ground it appears to be twisted 
inward. The sole of the shoe, if it is to enclose and support the 
bearing surface, must conform to this inward turn. It must be 
straight along the inner border to follow the normal line of the 
great toe, and a wide outward sweep will be necessary in order 
to include the outline and thus avoid compression of the outer 
border of the foot (Fig. 478). 

This demonstration of the true form of the foot is almost an 
indispensable preliminary to an intelligent discussion of the 
relative merits of shoes, and, indeed, it is somewhat of a revela- 
tion to those who have thought of the foot only as it has been 
subordinated to the arbitrary and conventional standard of the 
shoemaker. The shoemaker's foot, to which lasts conform, is much 
narrower than the actual foot; the great toe is not a powerful 
movable member, provided with active muscles, but is small and 
turns outward, so that the forefoot is somewhat pyramidal in 
form and turns upward as if to avoid contact with the ground. 



748 



OR TH OPE DIC SURGERY 



This imaginaiy foot, drawn after the shape of the ordinary last, 
appears in the diagrams (Figs. 479 and 480). Upon it the sole 
of the shoe has been indicated, to contrast it with the shape of 





Proper soles for normal feet. 



that necessary to include the outline of the normal foot. The 
actual foot is thus compressed laterally by the shoe until the 
stretching of the leather, during the " breaking-in" process, 
allows it to overhang the sole. The great toe is forced outward, 




Shoemaker's feet. 




Shoemaker's soles. 



and, with its fellows, is compressed, distorted, and lifted off the 
ground by the rocker-shaped sole (Fig. 482). Finally, although 
in the foot there is a well-marked metatarsal arch (convexity 



DISABILITIES AND DEFORMITIES OF THE FOOT 749 

upward), the sole is almost invariably fashioned with a convexity 
downward. Thus the foot, according to the age at which the 
reshaping process is begun and the constancy of the application, 
is gradually changed in shape and altered in function (Fig. 481). 
This remodelling, however, is often accompanied by such dis- 
comfort that the individual rebels and wears a shoe with a square 

Fig. 481 




Skiagram of a foot modelled to fit the shoe, illustrating the etiology of hallux valgus. 

toe, which, from the conventional standpoint, is supposed to show 
a meritorious effort to follow nature. But the demonstration of 
the actual foot makes it evident that it is a properly shaped sole, 
which serves as a support, not the part which projects beyond 
the foot, that is of importance. If the shoe with the square toe 
is wider, and straighter on the inner side than another with a 



750 ORTHOPEDIC SURGERY 

pointed toe, it is in so far an improvement. But, as a matter of 
fact, one of the worst types of shoe provided for children, in 
shape very like the old-fashioned coffin-lid, owes its popularity 
to the square toe. The same comment may be made on the 
so-called "common-sense" shoe. 

The object of the heel is to make walking easier by inclining 
the body somewhat forward. The high, narrow heel is an inse- 
cure support, which induces deformity by throwing more strain 
upon the forefoot and pushing it forward into the narrowest part 
of the shoe. The heel is, of course, unnecessary in childhood, 
and should not be worn, since it limits the necessity for and there- 
fore the use of the normal range of motion at the ankle-joint. 
The ordinary shoe, by restricting the functional use of the foot, 
favors awkwardness and improper attitudes. It compresses 
the toes, and is directly responsible for corns, bunions, ingrown 
toe-nails, and deformities, and indirectly it causes or aggravates 





The rocker sole. The flat sole. 

nearly every weakness to which the foot is liable. This assertion 
does not need support of argument, since in some degree it has 
been proved by the personal experience of every shoe wearer. 

The shape of the proper shoe corresponding to the undistorted 
foot has already been demonstrated (Fig. 478). The sole should 
be thick enough for protection, but not so rigid as to limit normal 
motion; it should follow the imprint of the foot, projecting 
somewhat beyond the outline of the toes; it should be flat from 
end to end and from side to side (Fig. 483), and the upper leather 
should be capacious. In other words, the front of the shoe should 
be designed to permit and to encourage normal functional activity, 
the slight adduction of the great toe, and the alternate expan- 
sion and contraction of its fellows, as may be observed in the 
barefoot child. The heel should be broad and low. Most adult 
feet are more or less deformed, and, therefore, better suited by an 
improved than by a perfect shoe. Of this class, what is known 
as the wide Waukenphast pattern is the best. In selecting shoes, 



DISABILITIES AND DEFORMITIES OF THE FOOT 751 

the breadth of sole, the angle of outward deviation of the soles 
when the two are placed side by side, and the capacity of the 
upper leather must be the determining points. 

The most effective work for reform can be accomplished by 
providing proper shoes for children and thus preventing deformity. 
The inspection of children's feet shows that atrophy and com- 
pression begin at a very early age, and if protection could be 
assured during the period of rapid growth, serious distortion 
might be prevented. 

Socks. — Although of far less importance than the shoes, the 
socks worn by children deserve special mention as a factor in 
deformity, since they are often too short and too narrow and are 
made of unyielding material, so that the proper action of the toes 
is restrained. Theoretically, the socks, like the shoes, should be 
rights and lefts; but if they are sufficiently large and of a texture 
to expand readily to the shape of the foot, but little trouble need 
be anticipated on this score. 



CHAPTER XXII. 

DEFORMITIES OF THE FOOT. 

Talipes. 

In the preceding chapters the disabilities of the foot, of which 
the symptoms of pain and discomfort were of greater importance 
than actual deformity, have been described. One now passes to 
the consideration of the congenital and acquired disabilities, of 
which deformity is the most noticeable feature. 



f ■ 

I mm 



Paralytic equinus. Recovery from paralysis, but deformity persists. 

Distortions of the foot are, practically, fixed positions in normal 
attitudes or what are exaggerations of normal attitudes; in other 
words, the ordinary deformities can be voluntarily simulated, and 
the centres of motion, at which the foot is deformed, are the 
centres of normal motion. If the foot has been fixed in the 



DEFORMITIES OF THE FOOT 753 

abnormal attitude during the period of formation and rapid growth, 
or if it has been used for any length of time in the abnormal posi- 
tion, the deformity becomes exaggerated beyond the possibility of 
imitation, and secondary variations in its shape, size, and nutrition 
follow. 

The deformities of the foot are grouped under the generic 
name of talipes, derived from talus (ankle) and pes (foot), signify- 
ing, therefore, a form of deformity in which the patient walks 
upon his ankles. Talipes was thus originally synonymous with 
the popular term club-foot, but at the present time it is used 
simply as a prefix to the descriptive titles of the different distor- 
tions, while club-foot is usually applied only to the most common 
of the congenital deformities, equinovarus, in which the distorted 
foot is club-like in form. 

Varieties. — There are four simple varieties of the distorted foot 
or talipes. 

1. Talipes Equinus, the extended or plantar flexed foot. In well- 
marked cases the patient walks upon the heads of the metatarsal 
bones, an attitude that suggested the name equinus (horse-like). 

2. Talipes Calcaneus, the dorsiflexed foot, in which the heel is 
prominent, and which alone bears the weight in walking; hence, 
calcaneus from calcaneum, the heel bone. 

In these forms the centre of motion is at the ankle-joint. 
Under the terms equinus and calcaneus are included not only the 
cases of marked deformity, but also those in which the range of 
dorsal or plantar flexion is sufficiently limited to interfere with 
function, even though the change in the contour of the foot is 
slight. 

3. Talipes Varus, the inverted foot. In this deformity the foot 
is turned in or adducted, and combined with the inward twist 
there is practically always a corresponding degree of inversion; 
that is, the inner border of the sole is elevated and the outer border 
is depressed, so that the weight falls to the outer side of the centre 
of the foot. 

4. Talipes Valgus, the everted foot. This deformity is the reverse 
of varus. The foot is abducted and the sole is everted, so that 
in use the weight falls on the inner border. 

In these forms of lateral deformity the centres of motion are at 
the mediotarsal and subastragaloid joints. 

Compound Deformities. — Simple deformities, in which the foot 
is persistently extended or flexed, or twisted in or out, are com- 
paratively uncommon. More often they are combined in varying 



754 



OB THOPEDIC S UB GEB Y 



degree; thus the oxerextended or the overflexed foot is usually 
twisted inward or outward, making four varieties of compound 
deformity : 

1. Talipes Equinovarus, the extended and inverted foot. 

2. Talipes Equinovalgus, the extended and everted foot. 

3. Talipes Calcaneo varus, the flexed and inverted foot. 

4. Talipes Calcaneovalgus, the flexed and everted foot. 

In the various forms of talipes the arch may be increased or 
diminished in depth. It is, for example, usually increased in 




Congenital calcaneus. In this form (simple calcaneus) the arch is obliterated. 
In the acquired form (calcaneocavus) it is increased. 



calcaneus and equinus, and it is usually diminished in valgus; 
but this secondary or subordinate deformity is not recognized 
in the ordinary classification. If the arch of the foot is simply 
exaggerated, the condition is sometimes called pes cavus; if it is 
lessened or lost, it is called pes planus. These slight degrees of 
distortion, in which the functional disability is usually more im- 
portant than the deformity, are rarely classed as forms of talipes. 
Simple cavus, the hollow or contracted foot, and pes planus, one 



DEFORMITIES OF THE FOOT 



755 



of the forms of the common weak or flat-foot, have been described 
elsewhere. (Chapters XX and XXI.) 

Etiology — From the remedial standpoint, the cause of the 
deformity is of far greater importance than its form. Thus, one 
divides the distortions of the foot into two groups : 

1. The Congenital Form, in which the foot, in process of forma- 
tion, has slowly grown into deformity before birth. 

2. The Acquired Form, in which the foot, perfect at birth, has at 
a later time become distorted. 

The congenital club-foot may be considered simply as a twisted 
foot, of which the component parts, although distorted to a greater 
or less degree, are capable of regaining perfect form and function. 
This is practically true of the great majority of cases, although 




Congenital valgus. 

there are instances in which congenital deformity is complicated 
by defective formation of the foot or leg, or in which the defor- 
mity is caused or at least accompanied by paralysis; as, for example, 
in certain forms of spina bifida or other congenital defect or dis- 
ease of the nervous apparatus. 

The acquired deformity is nearly always a consequence of 
disease of the spinal cord (anterior poliomyelitis). Certain 
muscles or groups of muscles being paralyzed, usually in early 
childhood, the muscular force of the foot is unbalanced, and it is 
drawn into a distorted position by the contraction of the un- 
opposed muscles and by the influence of gravity. This distortion 
is confirmed and increased by the accommodative changes in 
structure that accompany functional use and growth in the 
abnormal attitude. 



756 ORTHOPEDIC S UBGEB Y 

Far less often acquired talipes may be the result of paralysis of 
cerebral origin, of other forms of disease of the spinal cord, or of 
local paralysis following neuritis or injury to a nerve trunk. It may 
be caused by scar contraction, as after a severe burn, or by direct 
injury, or by disease that may interfere with subsequent growth 
(Fig. 289). Such are, however, extremely uncommon causes. 
Thus it is evident that while congenital talipes is a simple 




Congenital club-hands and feet, combined with anchylosis of nearly all the joints. 
(Compare with Fig. 488.) 

distortion capable of perfect cure, acquired talipes is capable 
only of rectification and not of perfect cure unless recovery from 
the original disease, of which it is a result, has taken place. 

Etiology of Congenital Talipes. — As of other congenital defor- 
mities, the etiology of talipes is more or less conjectural. Occa- 
sionally the influence of inheritance is apparent, and, again, two 
or more children with club-foot may be born of the same mother; 



DEFORMITIES OF THE FOOT 



757 



but, as a rule, nothing bearing upon the deformity appears in 
the family or personal history. The most reasonable explanation 
as applied to the majority of cases is the mechanical. This is, 
in brief, the theory that the foot has from some cause remained 
for a longer or shorter time in a constrained or fixed position, 
and has thus grown into deformity. 

It has been claimed by Eschricht 1 and also by Berg 2 that about 
the third month of intrauterine life the thighs of the embryo 




The etiology of congenital club-hands, club-foot, and anchylosis of the joints. The habitual 
attitude at birth. Photograph at age of three months. (See Fig. 487.) 

are abducted, flexed, and rotated outward, the legs are crossed, 
and the feet are plantar flexed and adducted, so that the inner 
surfaces of the thighs, the tibial borders of the legs, and the plantar 
surfaces of the feet are held in close apposition to the abdomen 
and to the pelvis of the foetus. Later there is an inward rota- 
tion of the legs, so that the feet are turned gradually outward 
until the soles are brought into contact with the uterine wall, the 

i Deutsche Klinik, 1851, No. 44. 

a Berg, Archives of Medicine, New York, December 1, 1882. 



758 ORTHOPEDIC SURGERY 

feet then being in the attitude of abduction and dorsal flexion. 
According to this theory, there is a regular succession of attitudes 
during intrauterine life. If the inward rotation of the lower 
extremity is prevented or if it is incomplete, the foot, remaining 
in the original position, becomes deformed. Thus equinovarus, 
being the normal attitude of the early and middle period of intra- 
uterine life, is not only the most common, but it is the most 
intractable of the congenital deformities. But if the constraint 
or pressure is not exerted until a later period, after rotation has 
taken place, when the foot has attained or nearly attained its 
normal size and shape, it will then induce the rarer and compara- 
tively slight grades of deformity, such as calcaneus or valgus. 

This theory, which seems interesting and reasonable, appears 
to rest on a very insecure basis. Bessel Hagen 1 states that in 
embryos of 30 mm. in length the foot is in extreme plantar 
flexion; in those of 90 to 100 mm. the foot is at a right angle to 
the leg; and from this size to that at full term the foot may be 
found in any position — abducted, adducted, or dorsiflexed. He 
states, also, that inversion is not the usual attitude at an early 
period, but is more common near the termination of intrauterine 
life, and when it is present it is more often combined with dorsi- 
flexion. In other words, there is no time when the foot regularly 
and normally assumes the attitude of club-foot, from which it is 
changed by the rotation of the limbs. Scudder, 2 after similar 
investigations, arrived at practically the same conclusions. He 
states that there is no necessary relation between the age, the 
rotation of the limbs, and the position of the feet. 

Although the rotation theory may not be absolutely accepted, 
still it would appear that there is, during the process of develop- 
ment, a normal alternation of posture of the limbs and feet. If 
they are fixed in one position during this period of rapid growth, 
distortion must follow; if the constraint is slight, and if its in- 
fluence is exerted at a late period, the deformity will be slight; 
if it persists from an early period, the deformity will be extreme 
and resistant. 

One of the causes of constraint, and thus of ultimate deformity, 
appears to be the interlocking of the feet. Many museum speci- 
mens show this, and in some of the cases of talipes seen during 
the first weeks of life the feet may be replaced in the attitude in 
which they had been fixed before birth (Fig. 310). Intrauterine 

1 Die Pathologie und Therapie des Klunipfusses Heidelberg, 1899. 
- Boston Medical and Surgical Journal, October 27, 1887. 



DEFORMITIES OF THE FOOT 



759 



pressure, although not usually the direct cause of club-foot, 
undoubtedly has an influence in aggravating the deformity. The 
effect of pressure is not infrequently shown in atrophic areas of 
skin, and bursse even are sometimes found o\er prominent bones. 

Entanglement in the umbilical cord, the direct pressure of intra- 
uterine or extrauterine tumors and the like may be mentioned 
also as possible causes. 

Evidence of restraint and of abnormal attitudes of the limbs is 
seen not infrequently in connection with club-foot; for example, 




Intrauterine "amputations." The patient. is a. tailor. 



in hyperextension or fixed flexion of the knees, and in cases of 
extreme deformity, the foot is often smaller than normal and 
otherwise asymmetrical. The distorted foot may be imperfect 
in structure; toes may be absent, "spontaneous amputation" 
(Fig. 489) or constricting bands about the leg or foot may be 
present. Such abnormalities are usually ascribed to amniotic 
adhesions. Talipes may be combined with evidences of impaired 
or arrested development; with harelip, extrophy of the bladder, 
spina bifida, and absence of patella?; or with other deformities, 
such as club-hand and wryneck, fixed flexion at the knees, and 



760 ORTHOPEDIC SURGERY 

the like; or there may be evidence of intrauterine disease, as 
in anchylosis of joints (Fig. 488) or so-called fcetal rickets. 
Finally, deformities of the foot may accompany or are caused by 
absence of bones, as of those of the foot; or other deformities and 
malformations, showing evidently an abnormality in the original 
make-up of the germ. This latter group, which includes the 
complications of club-foot and imperfection of structure, is com- 
paratively small, for, as has been already stated, in the great 
majority of cases congenital club-foot is a simple deformity capable 
of perfect cure. 

Statistics. — The most accurate statistics are those compiled 
from the records of the Hospital for Ruptured and Crippled, 1 
of 4718 individual cases of talipes. Of these 2103 were congenital 
and 2615 were acquired. The relative frequency of the congenital 
and acquired forms of talipes has given rise to much discussion in 
the past, and statistics on this point are at considerable variance 
with one another. This may be explained by the fact that acquired 
talipes is, as a rule, a preventable deformity. At the present 
time the extreme degrees of acquired talipes are comparatively 
rare, and the deformity is usually of a much slighter grade than 
the corresponding form of congenital distortion. 

Males. Females. Total. 

Sex of congenital talipes .... 1355 748 2103 

Percentage 64.4 35.6 

Sex of acquired talipes .... 1416 1199 2615 

Percentage 54.1 45.9 

Congenital talipes is much more common among males than 
among females. All statistics are in accord upon this point. 
Acquired talipes is more equally divided between the sexes. 

Right. Left. Both. Total. 
Foot affected in congenital talipes . . 643 552 908 2103 

Percentage 30.4 26.1 43.5 

Unilateral 1195 = 57. 5 per cent. Bilateral 918 = 43. 5 per cent. 

Right. Left. Both. Total. 
Foot affected in acquired talipes . . . 1126 1102 387 2615 

Percentage 43 42.1 14.9 

Unilateral 2228 = 85. 1 per cent. Bilateral 387 = 14. 9 per cent. 

In congenital talipes the deformity is nearly as often of both 
as of one foot, while in the acquired form unilateral deformity is 
far more common. In each variety the right foot appears to be 
more often affected than the left. 

1 W. R. Townsend, A Statistical Paper on Club-foot. Transactions of the Medical 
Society of the State of New York, 1890. These statistics of cases have been supple- 
mented for me by Drs. Waller and Weingarten. 



DEFORMITIES OF THE FOOT 



761 



The Relative Frequency of the Different Forms of Congenital 
Talipes. 

Cases. Percentage. 

Equinovarus 1629 77.4 

Valgus 144 6.8 

Varus 89 4.2 

Calcaneovalgus 87 4.1 

Equiuus 49 2.3 

Calcaneus 47 2.2 

Equinovalgus 35 1.6 

Calcaneovarus 10 

Cavus 5 

Valgocavus • 1 

Equinocavus 1 

Different deformity in each foot 54 



Relative Frequency of the Different Forms of Acquired Talipes 
Together with the Etiology. 











Spinal. 


Cerebral. 


Other 




















Anterior 

polio- 
myelitis- 


Hemi- 
plegia. 


Para- 
plegia 


forms of 
paralysis 


Trau- 
matic. 


Total. 


Per ct. 


Equinovarus .... 


610 


59 


41 


18 


56 


784 


30 


Equinus 
Calcaneus 








469 


102 


50 


14 


43 


678 


25.9 








313 


7 


3 


9 


20 


352 


13.4 


Valgus . 








205 


6 


10 


1 


37 


259 


9.9 


Equinovalgus 








163 


1 


5 


1 


7 


177 


6.7 


Calcaneovalgus 








123 


1 


1 


1 


15 


141 


5.4 


Varus 








68 


8 


3 


1 


10 


90 


3.1 


Calcaneocavus 








13 





1 


1 





15 


0.5 


Equinocavus 








38 











2 


40 


1.5 


Calcaneovarus 








15 








1 


1 


17 


0.6 


Cavus . 








48 


1 


1 





4 


54 


0.2 


Varocavus . 








2 


1 


1 








4 






2067 


186 


116 


47 


195 


2611 




Deformity different on each side 
















Anterior poliomyelitis 






2067 = 79 


9 per ce 


nt. 




Cerebral .... 






302 = 11 


5 






Traum 


a tic 












195 = 7 









Comparative Frequency of the Different Forms of Talipes, 
Congenital and Acquired. 

Congenital. Acquired. 

Equinovarus . . . . 77. 4 per cent. 32. 5 per cent. 

Valgus 6.8 " 9.7 

Varus 4.2 " 2.7 

Calcaneovalgus .... 4.1 " 4.4 

Equinus 2.3 " 26.1 

Calcaneus 1.6 " 12.6 



It will be noted that in three-fourths of the congenital cases 
the deformity is equinovarus, and that equinus and calcaneus, 
rare as congenital deformities, comprise 38 per cent, of the acquired 
forms. 



762 ORTHOPEDIC SURGERY 

Occasionally the deformity is different in each foot, far more 
often in the acquired than in the congenital form (147 of the former 
or 30 per cent., of the 484 acquired bilateral deformities as com- 
pared with 54, or less than 6 per cent., of the bilateral congenital). 
In 7 of 18 of the congenital cases the deformity was equinovarus 
on one side, calcaneus on the other; in 3, equinovarus and cal- 
caneovalgus, and in 3, simple varus and valgus. In congenital 
cases the most common combination is equinovarus on one side 
and calcaneus on the other. Next equinovarus and calcaneo- 
valgus. 

In 31, or 4 per cent., of 735 cases of congenital talipes tabu- 
lated by Waller the distortion was combined with other con- 
genital defects or deformities, viz., in 12 cases with double club- 
hands; in 6 cases with defective development of the hands, webbed 
fingers, and the like; in 7 cases with spina bifida; in 3 cases with 
absence of one or more bones of the leg; in 1 case with torticollis 
in 1 case with harelip; in 1 case with dislocation of the knee and 
anchylosis of an elbow; in 2 cases with general rigidity and defor- 
mity of the joints. 

The Anatomy of Congenital Club-foot. Talipes Equinovarus — 
Congenital talipes is, in the great majority of cases, the form in 
which the foot is twisted inward and downward, so that in extreme 
cases it resembles the club-like extremity that has received the 
popular name of club-foot. The ordinary congenital club-foot 
in early infancy is simply a foot held in an exaggerated attitude 
of plantar flexion, adduction, and supination. The dorsum of 
the foot looks forward and slightly outward and upward, the 
plantar surface is abnormally concave, and looks backward, 
inward, and downward. The foot often seems somewhat smaller 
than normal, and the heel appears to be ill-formed. Upon the 
outer dorsal surface the body of the displaced astragalus projects; 
the external malleolus is prominent, while the internal malleolus 
lies deep beneath the redundant tissues of the internal aspect of 
the foot. 

In many instances the turning inward of the foot is so extreme 
that it conceals the equinus element of the deformity (Fig. 490). 
Thus equinovarus is often classified as varus, especially by English 
authors. 

The internal structure of the foot corresponds to the external 
contour; thus the relation of the bones to one another, and even 
the shape of the individual bones, are more or less altered as the 
deformity is more or less of an exaggeration of the attitudes that 



DEFORMITIES OF THE FOOT 



763 



the normal foot is capable of assuming. These changes are most 
marked in the astragalus and os calcis. The astragalus is thicker 




Typical congenital equinovarus (club-foot). 
Fig. 491 





The deformities of the astragalus in club-foot: A, astragalus of a normal infant; 1, from 
above; 2. from within; 3, from without. B, the astragalus in club-foot in the same posi- 
tions. (Adams.) 

at its external than at its internal border, or somewhat wedge-shaped 
from without inward; it is plantar flexed, so that a large part of 
its body protrudes from between the malleoli. Its neck is often 



764 ORTHOPEDIC SURGERY 

somewhat longer than normal, and it is, as a rule, depressed and 
deflected inward (Fig. 491, B). The os calcis is also in an attitude 
of plantar flexion; the internal tuberosity is drawn upward to the 
vicinity of the internal malleolus, its anterior extremity looks down- 
ward and inward, and it is often bent inward, corresponding 
to the deformity of the neck of the astragalus. Its external sur- 
face looks downward and forward, and it lies directly beneath 
the astragalus instead of to its outer side, as in the normal relation. 

The navicular is drawn inward and upward, and articulates 
with the inner part of the deflected head of the astragalus; it 
lies in close proximity to and is often in contact with the internal 
malleolus; the cuboid is displaced upward and inward, and lies 
to the inner side of the anterior extremity of the os calcis. The 
remaining bones are changed in position, but not materially in 
shape. In many instances the tibia is rotated inward upon the 
femur, and this inward rotation of the leg may persist after the 
deformity of the foot has been corrected. Less often the tibia is 
slightly twisted inward on its long axis. In other cases there is 
often a moderate degree of knock-knee and laxity of the liga- 
ments at the knee. As a rule, however, these are secondary or 
compensatory effects of club-foot that do not appear until the 
child begins to walk. 

The ligaments are altered to correspond to the changed rela- 
tions of the bones. Those on the short side are more or less 
resistant, according to the duration of the deformity. The mus- 
cles are normal as to their structure and their origin and insertion, 
but the direction of the tendons as they pass across the foot is 
altered somewhat. Those attached to the inner side, the extensor 
and adductor group, are shortened and are relatively stronger 
than the opposing muscles which are lengthened and atrophied 
from disuse. 

To sum up: all the component parts of the foot participate in 
the deformity. The most resistant structures of the deformed 
foot are the plantar fascia and the ligaments that bind the navicular, 
the os calcis, and the internal malleolus to one another. The 
muscles that are most active in retaining and increasing the 
deformity are the tibialis anticus, the tibialis posticus, and the 
combined gastrocnemius and soleus. 

The changes that have been outlined, which are comparatively 
slight and which may be easily rectified soon after birth, become 
more marked as the part develops; and when the child begins 
to walk the weight of the body, combined with growth and 



DEFORMITIES OF THE FOOT 



765 



functional use in the abnormal position, increases and fixes the 
deformity. 

In the adolescent or adult type of club-foot that has never 
been treated, the deformity is so extreme that the patient actually 
appears to walk on the outside of his ankles, as the term talipes 
implies. The feet turn directly inward, or even inward, upward, 
and backward, and the peculiar walk, by which interference of 
inverted feet is avoided, has 

given another name (reel FlG - 492 

foot) to the deformity. 

In such cases knock-knee 
is usually well marked. This, 
although it may be present 
at birth, is, as has been 
stated, usually a secondary 
distortion caused in great 
part by the accommodation 
to the deformity; that is, by 
the diminution of the base 
of support and by the inter- 
ference of the feet (Fig. 495.) 

The legs are shrunken 
from disuse. Over the outer 
border of the foot, in the 
neighborhood of the calca- 
neocuboid articulation, there 
is a large callus with an 
underlying bursa . The foot 
itself is atrophied and is 
smaller than the normal. 
The changes in the bones 
are much more marked ; only 
a small part of the articu- 
lating surface of the astrag- 
alus lies between the mal- 
leoli, and this posterior ex- 
tremity is flattened out to the shape of a wedge. Thus, the leg 
bones appear to be displaced backward, a change most apparent 
in the position of the external malleolus. The bones of the foot 
are more or less atrophied, and the normal area of cartilage has, 
to a great extent, disappeared from the articular surfaces of the 
disused joints. 




Talipes equinovarus in adolescence, apparently 
of the acquired form, showing the displacement of 
the astragalus and its relation to the scaphoid, also 
the atrophy and distortion of the bones of the leg. 



766 



ORTHOPEDIC SURGERY 



In these neglected cases the foot is practically a simple rigid 
support, to which the patient has been so long accustomed that 
he may walk with comparative ease and with no discomfort 
other than that caused by the corns and bunions at the pres- 
sure points. In such cases, cure in the sense of perfect functional 
recovery is, of course, out of the question; but relief of the defor- 
mity — that is, replacement of the foot in the axis of the leg, at 




Talipes equinovarus. 
The tendons on the front of the foot. Showing the tendons in the sole of the foot and 

the extreme displacement of the os calcis. 



a right angle to it and in the plantigrade attitude — is nearly always 
possible. 

Symptoms. — The symptoms of congenital club-foot have been, 
to all intents, included in the description of the deformity. The 
functional disability is, of course, considerable, although some 
patients are surprisingly active and are able to walk long dis- 
tances. As the discomfort from club-foot is due almost entirely 



DEFORMITIES OF THE FOOT 767 

to the corns or inflamed bursse over the bony prominences, its 
character depends, of course, upon the use to which the foot is 
subjected. 

Treatment. — In considering the treatment of congenital club- 
foot it is customary to divide it into several classes corresponding 
to the degree of resistant deformity. 

The first class would include the very slight or non-resistant 
cases in which the deformity may be almost entirely corrected by 
slight manual force. 

The second class comprises those cases in which a certain 
amount of varus and well-marked equinus persist, which it is 
impossible to overcome by manipulation. 

The first and second classes include the forms of infantile 
club-foot. 

The third class comprises the cases of more extreme deformity 
and those in which the resistance to the correction is great, as in 
many of the cases in early childhood or those of later years that 
have been inefficiently treated. 

A fourth class would include the untreated cases in the adoles- 
cent or adult. 

Congenital club-foot (talipes equinovarus) treated at the proper 
time — that is to say, in early infancy and in a proper manner in 
a great majority of cases may be perfectly cured both as to form 
and function. 

The club-foot in childhood, in which treatment has been de- 
layed or in which it has been ineffective, may be practically cured 
as to form and function, but a certain amount of atrophy of the 
foot and leg persists as a consequence of the disuse of the dis- 
torted part. 

Club-foot in the adult may be made straight, but restoration 
of perfect function is, of course, impossible. 

Although congenital club-foot is an eminently curable defor- 
mity, yet perfect and permanent cure requires minute attention 
to details during the active stage of treatment, supplemented by 
careful supervision long after the cure is supposed to be com- 
plete. No other deformity presents such a record of failures 
and incomplete cures, of relapses after apparent cure, of tedious 
and ineffective treatment by braces, and of unnecessary and 
mutilating operations. Some of the failures may be explained by 
the neglect of the parents or by want of opportunity. A few are 
due to the unusual obstacles in the deformity itself, but by far 
the greater number must be accounted for by failure of the 



768 ORTHOPEDIC SURGERY 

physician to apprehend the true nature of the deformity or by his 
inexperience in the practical details of treatment. 

Principles of Treatment of Infantile Club-foot. — The infantile 
club-foot is, as has been stated, simply a twisted foot. It is true 
that there are slight changes in the bones; but the bones of an 
infant's foot are represented by yielding cartilage, which will 
rapidly reform under changed conditions. The shortened liga- 
ments, which are accommodated to the deformity, may be easily 
stretched, together with the more resistant muscles and their 
tendinous insertions, and when the proper relation of the bones 
to one another has been restored the joints will undergo an 
accommodative transformation. 

The treatment of club-foot may be divided into three stages: 

1. The rectification of the external deformity. 

2. The support of the foot in proper position during the process 
of transformation of its internal structure and until the normal 
muscular power, unbalanced by the deformity, has been regained. 

3. The period of supervision. This would include the treat- 
ment of possible complicating deformities at the knee, the laxity 
of ligaments and the like, as well as the oversight of the func- 
tional use of the foot and the limb during the early years of 
life. 

On examining the infantile club-foot one will notice a certain 
measure of the muscular activity that characterizes the normal foot. 
The normal infant moves the foot in various directions, in a more 
or less regular alternation of postures, but the motion of the club- 
foot is in one direction only, that toward which the foot is turned. 
The muscles on the back and inner side of the leg, which are alone 
active, become relatively irritable and hypertrophied as compared 
with those on the front and outer side that are disused. Thus 
movement of the deformed foot is in reality harmful, be- 
cause it increases deformity and still further disturbs the mus- 
cular balance. For this reason the temporary restraint of motion, 
necessary during the rectification of the deformity, may be con- 
sidered rather of advantage than otherwise. When movement 
is again allowed and encouraged it must be in the directions 
opposed to the attitudes of deformity, with the aim of so strength- 
ening the weakened group of muscles at the expense of the stronger 
that the balance of muscular power may be regained. 

The First Stage of Treatment. Rectification of Deformity. — It 
should be stated at once that "rectification of deformity" does 
not mean apparent symmetry, a misapprehension to which the 



DEFORMITIES OF THE FOOT 769 

majority of failures in treatment may be ascribed. It means that 
when deformity is really rectified all contracted and resistant 
parts must have been so elongated that every passive motion and 
attitude possible for the normal foot is equally possible and as 
easily attained in that which was deformed. This is functional 
rectification as contrasted with the simple correction of deformity. 

The most important part of the club-foot deformity is varus. 
The foot that is rolled over and twisted inward to the attitude 
of extreme inversion (Fig. 490) must be untwisted and forced 
into an attitude of extreme abduction or valgus, the so-called 
overcorrection (Fig. 486). Until this is accomplished no atten- 
tion whatever need be paid to the residual equinus. There are 
two reasons for dividing the procedure into two parts: First, that 
the attention of the surgeon may be concentrated on one and the 
most important part of the deformity; second, because by this 
preliminary untwisting the os calcis is brought into the upright 
position, into its proper relation to the astragalus, to the bones 
of the leg, and to the tendo Achillis, so that the true degree of 
equinus may be appreciated. 

Preliminary Manipulation. — As a ride, the second or third week 
of life is as early as mechanical treatment can be undertaken. 
Until then preliminary manipulation by the nurse, more particu- 
larly manual straightening of the deformity by gently drawing the 
foot toward abduction and retaining it in the improved position 
for a few minutes, as often as is possible, may be of service in over- 
coming its resistance. As a treatment by itself, however, simple 
manual correction is tedious and ineffective, although partial 
cures have been attained by perseverance in this means alone. 

Mechanical Treatment. — This is the treatment of choice and 
routine for infantile club-foot, and two methods may be described: 

1. By the plaster bandage. 

2. By some form of simple splint. 

The principle of the two is essentially the same. The foot is 
drawn toward an improved position and retained there by the 
plaster bandage, or it may be fixed to some form of metal splint 
or brace whose shape is gradually changed from week to week, 
as the resistance lessens. 

Gradual Rectification of Deformity by Means of the Plaster 
Bandage.— In this treatment care should be taken to avoid undue 
pressure, irritation of the skin, or insecurity of the bandage. One 
should place shreds of cotton between the toes; and the outer 
aspect of the ankle, where the skin is thrown into folds when 

49 



770 ORTHOPEDIC SURGERY 

the foot is straightened, should be smeared with vaseline. A 
narrow strip of adhesive plaster, long enough to reach from the 
knee to a point an inch or more below the heel, is applied to the 
outer side of the leg. A thin layer of cotton is wound about 
the leg, just below the knee, in order to protect the skin from the 
hard margin of the plaster bandage, and a similar strip is carried 
about the toes. The foot is then drawn gently toward the ab- 
ducted position as far as may be without causing discomfort. 
While it is held in this attitude a narrow bandage, preferably 
flannel or cotton flannel, is smoothly applied to the leg and foot, 




Neglected club-foot, showing the secondary knock-knee. 

the band of adhesive plaster being drawn out between the folds 
about the ankle. A very light plaster bandage is then applied 
from the extremities of the toes to the upper part of the leg, 
and into this bandage the projecting strip of adhesive plaster is 
incorporated, so that no displacement of the dressing is possible. 
The turns of both the plaster and the flannel bandage should be 
made from within, downward and outward, so that the tension aids 
in retaining the foot. When the plaster bandage, which during the 
hardening process has been constantly rubbed and manipulated so 



DEFORMITIES OF THE FOOT 771 

that it may fit the part perfectly, and which need not be thicker 
than blotting paper, has become firm, a long stocking is drawn 
over it and is attached to the body clothing. At the end of a 
week the bandage is removed. The leg and foot are gently bathed 
with alcohol, thoroughly dried, powdered, and protected as before, 
and the bandage is again applied. At this second dressing the 
irritable adducting muscles, after the interval of complete rest, 
will be much less active and the contracted tissues will be less re- 
sistant, so that the foot may be easily turned somewhat outward 
or beyond the line of the leg. 

After four or five applications of the bandage, at weekly inter- 
vals, the foot, in ordinary cases, can be held without resistance 
in the attitude of extreme equinovalgus. The sole, which at 
first looked backward, inward, and upward, will be turned in the 
opposite direction, forward, outward, and downward, and the 
inner border of the foot, which was concave, is now convex (Fig. 
486). When the varus has thus been overcorrected, treatment 
is directed to the secondary equinus. At first one carries the 
foot upward (toward dorsal flexion), while it is still retained in 
the abducted position, but after one or two treatments, when the 
right-angled attitude has been attained, it is brought nearer to 
the axis of the leg. The everted position, or the attitude opposed 
to varus, is retained, however, until correction is completed. Jn 
correcting the equinus a certain amount of force may be required, 
sufficient to cause some discomfort during the application of 
the plaster, but not sufficient to occasion suffering afterward. The 
force is applied to the entire foot, so that the posterior extremity 
of the os calcis may be drawn downward by actual lengthening 
of the tendo Achillis, and not, as is often the case, by an over- 
correction of the forefoot, while the heel remains in its original 
position of plantar flexion. By the proper application of force 
the equinus is gradually overcome; the sharp indentation or fold 
at the insertion of the tendo Achillis is lessened, and the heel 
becomes more prominent. 

The reduction of the equinus may be somewhat more difficult 
than that of the varus, but it should be entirely corrected in three 
or four months from the time of beginning the treatment. As 
has been stated, correction of the deformity implies overcorrection 
(Fig. 485) ; and it is well, when this has been attained, to hold 
the foot for several weeks, by means of the plaster bandage, in 
an attitude of extreme eversion and dorsal flexion (calcaneovalgus) 
in order to impress, as it were, the new position upon its struc- 



772 



ORTHOPEDIC SURGERY 



ture. This concludes the first stage of the treatment, the simple 
rectification of deformity. 

Correction by the plaster bandage has the great advantage 
of placing the treatment entirely under the control of the sur- 
geon. When properly applied, the support fits perfectly: it is 
light and clean, and it holds the foot in the desired attitude with- 
out undue pressure. 

The disadvantages of the treatment are due almost entirely to 
its improper application. For instance, the bandage may be too 




The first application of the plaster bandage, showing the 
(Compare with Fig. 490.) 



lproved position. 



heavy, or the padding may be so thick that it does not retain its 
position. Excoriations are usually due to carelessness in the 
application of the bandage, or because it is not removed in proper 
season. The fear of compression, of atrophy of muscles, of 
stunting the growth of the limb, is groundless. At the end of the 
treatment, the corrected foot is, as a rule, larger • than one that 
has remained untreated. The stunted foot is the result of non- 
treatment, or of ineffective treatment by braces or otherwise; not of 
the enforced rest necessitated by the proper reduction of deformity. 



DEFORMITIES OF THE FOOT 



773 



The Rectification of Deformity by Splints and Braces. — Of 

mechanical supports there are many varieties. Complicated 
appliances should be avoided because they are unnecessary and 
because they serve to distract attention from the prime object of 
treatment, the rapid and systematic correction of deformity. Of 
the simpler braces that used by Judson is one of the best and 
will serve as a type to illustrate this form of treatment. The 
method of application may be described in Judson's own words: 
"The apparatus which I have conveniently used to effect this 
reduction before the child learns to stand is a simple retentive 
brace which acts as a lever, making pressure on the outer side 



H I J. 







Fig. 501 



Fig. 503 





The Judson club-foot splint and its application. 

of the foot and ankle at A, in Figs. 497 to 500, inclusive, and 
counterpressure at two points, one on the inner side of the leg 
at B, and the other at the inner border of the foot at C. It is 
advisable to keep in mind that this simple instrument is a lever, 
because if we know that we are using a lever with its three well- 
defined points of pressure we can make the apparatus more 
efficient than if we view it, in a more general way, as an apparatus 
for giving a better shape to the foot. 

"I use a little brace made of sheet brass, doing the work with 
a few simple tools. An advantage of doing the work one's self 
is that there is no room for doubt as to where the blame lies if 



774 ORTHOPEDIC SURGERY 

the apparatus does not work well. Two curved disks, B and C, 
Figs. 499 and 500, are riveted to a shank, D, and thus is formed 
that part of the brace which applies the two points of counter- 
pressure; while, on the other hand, the point of pressure is brought 
into action by a third disk or shield, A, which is drawn tightly 
against the outer side of the foot and ankle, and held in place 
by a strip of adhesive plaster, E, which includes the leg and the 
piece which connects the two disks, B and C. The disks are 
lined with two or three thicknesses of blanket, easily renewed, 
when necessary, with a needle and thread. These braces are so 
cheap and easily knocked together that it is nothing to apply 
new and larger ones, using heavier material for the shank as the 
child grows. In general, three sizes will be enough, the shanks 
being 12 gauge, f in. wide; 14 gauge, \ in. wide; and 16 gauge, f in. 
wide. The disks are conveniently made from 22 gauge, \\ in. 
wide. The rivets are copper belt-rivets, No. 13. A lip turned 
on the edges of the disks, with the flat pliers, gives stiffness to 
the thin brass and protects the skin from the rough edge. If 
more easily obtained, tin disks, light bars of iron or steel, and 
ordinary iron rivets would doubtless answer. 

"The brace is applied with three strips of adhesive plaster. 
The upper and lower pieces, E and G, Fig. 500, are simply to 
keep the apparatus in place, which they do effectively if ordinary 
gum plaster is used; while by drawing the middle strip E, tightly 
over the shield, and straightening the brace from time to time, 
the deformity is gradually and gently reduced. At each reappli- 
cation the brace is made a little straighter than the foot at that 
stage. This may readily be done by the hands, and then the 
adhesive strip is to be tightened over the shield until the shape of 
the foot agrees with that of the brace. After a few days the brace 
is to be made still straighter and again reapplied, and made tight 
until another point of improvement is gained. The brace is applied 
very crooked at the beginning of treatment, as in Figs. 499 and- 
500, and is straightened from time to time, and a longer brace 
applied as the deformity is reduced and the patient grows. It 
should be removed every week or two weeks, and an interval 
of a few days allowed for freedom from the brace, when the 
mother is advised to manipulate the foot constantly, using as 
much force as she will in the direction of symmetry. Manipu- 
lating the foot during these intervals is of great importance, as 
cases have occurred in which varus and equinus have been entirely 
overcome by the mother's hand alone. 



DEFORMITIES OF THE FOOT 775 

"By this simple and prosy treatment, carried out systematically 
and without haste, or violence or pain, the foot, unless it is a 
frightful exception, may with certainty be changed from varus to 
valgus. At the same time the tendo Achillis is lengthened until 
the position of the foot is near the normal, or at right angles 
with the leg, as the result of manipulation and giving the brace 
from time to time a partly anteroposterior action. Figs. 499 and 
500 show approximately the shape of the brace at the beginning 
of treatment; Figs. 501 and 502 when the varus is reduced, and 
Figs. 503 and 504 when valgus has taken the place of varus. 
The foot, in this latter stage, may not hold itself valgus when 
left to itself, but with almost no force and with one finger it may 
be pushed into valgus." 

When the varus deformity is reduced the equinus is gradually 
corrected by carrying the splint behind the internal malleolus; 
and, finally, if necessary, direct upward pressure may be applied 
by lengthening the brace and applying it to the posterior aspect of 
the foot and leg. It may be noted that manipulation and stretching 
the contracted parts when the brace is removed is of much im- 
portance in the correction of deformity by this or other means. 
Splints of wood, tin, felt, and the like may be employed, but they 
present no particular advantage over that which has been 
described . 

Tenotomy. — The equinus has been spoken of as the secondary 
deformity, but its complete correction is often more difficult than 
that of varus. In many instances, especially in the treatment of 
older children, time will be gained, after the foot has been forced 
into the position of equinovalgus, by the division of the tendo 
Achillis, which is the most resistant of the shortened tissues. 
After division of the tendon it may be necessary to use consider- 
able force to stretch the other contracted parts, and to force the 
foot up to the limit of normal dorsal flexion, which is the object 
of the operation. Occasionally the obstacle seems to be in the 
posterior ligament of the ankle, and it is sometimes of service to 
reinsert the knife and to divide this structure, in part at least, 
so that it will give way under manipulation. When the foot 
has been forced into the position of overcorrection it is fixed in 
a plaster bandage, which is allowed to remain for several weeks, 
until the interval between the separated ends of the tendon is 
filled in with the new tissue. 

In some instances the leg is rotated inward upon the thigh, 
and the habitual attitude is accompanied by accommodative 
changes in the ligaments of the knee-joint. During the treat- 



776 ORTHOPEDIC SURGERY 

ment of the club-foot this secondary distortion may be, in part 
at least, corrected by forcible manual rotation of the leg outward 
on the thigh several times daily. If the leg is slightly bowed it 
may be corrected by manipulation. (See bow-leg.) 

Recapitulation. — The routine treatment of infantile club-foot is, 
then: manipulation of the foot by the nurse from birth until 
systematic rectification can be begun; mechanical correction, 
first of the varus and then of the equinus deformity, terminating 
with a period of retention in the overcorrected position (calcaneo- 
valgus). Division of tendons, other than the tendo Achillis, is 
not often necessary. The time required for the overcorrection of 
deformity should not, under favorable conditions, exceed three 
months. 

The rapid correction of deformity in the manner described, 
begun as early as possible and accomplished as quickly as pos- 
sible, cannot be too strongly urged. In the first months of life 
the tissues are not resistant, the bones are practically entirely 
cartilaginous, and when the foot in its external appearance is 
rectified the rapid growth in the first months of life will change 
the internal structure to conform to the normal conditions. The 
fear of atrophy, compression, or other harm from the temporary 
fixation necessary during rectification is groundless, and, in fact, 
exercise, so-called, except in the directions opposed to deformity, 
is harmful rather than beneficial. 

Correction of deformity may be accomplished by holding the 
foot in an improved position by strips of adhesive plaster, or by 
the elastic traction of rubber bands attached to the leg and foot. 
As compared with the ease, rapidity, and certainty of correction 
by means of the plaster bandage such methods are uncertain and 
ineffective, and they need not be described in detail. 

The Second Stage of Treatment. Support and Restoration of 
Function. — When the deformed foot has been corrected,' in the 
sense that all normal motions can be carried out by passive force, 
the first and most difficult part of the treatment will have been 
completed, and, in some instances, the deformity is actually cured, 
as in the slighter types of cases treated in early infancy. Such a 
result is unusual, however, for although the foot may be normal 
in appearance, its muscular balance has not been restored. This 
is shown by the fact that when support is removed the foot usually 
hangs downward and inward, and there is little apparent power 



DEFORMITIES OF THE FOOT 777 

in the dorsiflexors and abductors to draw it upward and outward. 
If at this stage treatment were abandoned, the deformity would 
almost invariably recur, at least in part. For this reason the foot 
must be supported in proper position until the slack of the length- 
ened tissues has been taken up by development in the normal 
attitude, a development that maj- be aided by massage and other 
forms of stimulation of the muscles. Practically, support is always 
necessary until the child has begun to walk. 

The Retention Brace. — The form of retention brace will 
vary somewhat according to the indications of the individual case. 
The object is to hold the foot in what is called the overcorrected 
attitude — that is, dorsiflexion and eversion. This may be accom- 
plished by splints of pasteboard, leather, tin, and the like; but 
a light metal brace provided with a sole plate and upright, as 
shown in Figs. 478 and 484, is preferable. The best support is the 
Taylor brace, the invention of Dr. C. F. Taylor, of New York 
(Fig. 505). This consists essentially of a light upright that extends 
along the inner side of the leg to the knee, and a thin steel foot 
plate of the exact size of the sole, with an upright flange on the 
inner side, rising to a point just above the dorsal surface of the 
foot, against which the foot is pressed closely, so that recurrence 
of the varus deformity is prevented. The joint at the. ankle is 
provided with a catch that prevents plantar flexion, but allows 
dorsiflexion. By bending the upright and the sole plate the foot 
may be held in slight eversion. The apparatus is applied with 
straps, as illustrated, and, if necessary, its position is further 
fixed by a band of adhesive plaster, applied on the inner side 
of the leg to hold the heel firmly against the foot-plate. The 
foot is thus held constantly at a right angle to the leg, or, better, 
in the early stage of treatment, in an attitude of dorsiflexion and 
valgus. Occasionally, after complete rectification of the deformity, 
the foot still turns in. In most instances this is due to an inward 
rotation of the tibia on the femur at the knee-joint, but in 
some cases it is caused by a spiral twist of the tibia itself. In 
order to correct this secondary deformity an extension of the 
upright of the brace is carried beneath the leg, provided with a 
joint at the knee, and is extended up the outer side of the thigh. 
At the hip it is attached by a free joint to a padded pelvic band 
of light steel (Fig. 516). The band holds the upright in the 
proper relation to the thigh; thus, by twisting the part below the 
knee the foot can be rotated outward to the desired degree. In 



778 



OB THO PUBIC S UR GEE Y 



less marked cases the retention bands used for pigeon-toe may 
be employed (Fig. 471). 




The Taylor club-foot brace. 



Fig. 507 





Taylor club-foot brace, showing the method of application and attachment. 



DEFORMITIES OF THE FOOT 



779 



Methodical Manual Correction. — Several times during 
the day the brace should be removed in order that the foot may 
be thoroughly massaged and forcibly turned, first toward valgus 
— that is, outward at the mediotarsal joint — so that the inner 
border is made convex, and then to the extreme limit of dorsi- 
flexion and abduction. If the leg is rotated inward it is forcibly 
rotated outward on the femur. Even if the tibia is actually 
twisted on its long axis, the influence of the brace and forcible 
manipulation will usually correct the deformity. Active contrac- 
tion of the weak muscles may be induced by tickling the sole of 





The Taylor club-foot brace, showing the adhesive plaster, by means of which the heel is 
held down, and the method of attachment. This brace may be used to correct deformity as 
well as to retain the foot in proper position, as is illustrated by these figures. As a retention 
apparatus the foot-plate should be held at a right angle to the upright by the stop-joint 
shown in Fig. 505. 

the foot or by the use of electricity, and, finally, the entire limb 
should be thoroughly massaged before the brace is reapplied. 

When the deformity shows no tendency to recur the brace may 
be removed for a part of the day; later it is used only at night; 
and, finally, it may be discarded if the child walks normally. 
But it is best to continue the daily manipulation, more particu- 
larly the systematic stretching or overcorrection of the foot, for a 
long time. Thus one may assure one's self that there is no ten- 
dency toward deformity, of which the first symptom is always 
a slight limitation of dorsal flexion and of abduction. 



780 ORTHOPEDIC SURGERY 

In many instances the deformity may have been so thoroughly 
overcorrected by the plaster-of-Paris bandage or by the brace, 
and the after-treatment of massage and stretching may have been 
so efficiently applied by the nurse or parent, that the retention 
brace may be unnecessary. On the other hand, the inclination 
toward deformity may be so marked that a brace may be neces- 
sary to hold the foot in slight abduction and valgus for a year 
or longer. In other cases the use of a light brace to hold the 
foot in the overcorrected position during the night is alone required. 
These are points to be decided by the circumstances in each case. 
The period of observation and supervision is included in the final 
stage of the treatment. 

Third Stage of Treatment. Supervision. — During this period 
the attitudes of the limb and foot of the walking child must be 
carefully watched, and particularly the signs of wear on the sole 
of the shoe. If it shows greater wear on the outer side than is 
usual it is an indication that the weight does not fall directly on 
the centre of the foot, and that there is, therefore, a tendency 
toward deformity. This must be counteracted by making the 
sole thicker on the outer side or slightly wedge-shaped, so that 
the weight may be deflected toward the inner border. 

This third period of treatment, or, rather, of oversight of the 
functional use of the foot, must be continued indefinitely. In 
fact, it is the quality of this final supervision that decides in most 
instances whether the ultimate outcome is to be what is called a 
satisfactory result or a perfect anatomical and functional cure. 

The Treatment of Neglected Club-foot.— The treatment of 
club-foot, under what may be called the proper conditions, as out- 
lined in the preceding pages, applies practically to all cases before 
the completion of the first year of life, and mechanical rectifica- 
tion may be successfully employed in cases far beyond this limit 
of age. As a rule, however, when the patient has walked for 
any length of time, the resistance of the tissues has increased 
to such an extent that more rapid and effective treatment is indi- 
cated. The investigations of Wolff have shown that the internal 
structure of the bones corresponds to their external contour, and 
that the structure and contour are adaptations to functional use. 
This internal structure is not, however, permanent, but is readily 
transformed to conform to changes in form or function. If, 
then, the external contour of the club-foot were suddenly reversed, 
and if the foot were used in this new attitude, a transformation 
of the internal structure of the bones and at the same time of 



DEFORMITIES OF THE FOOT 781 

their shape would begin at once. This would continue until 
both structure and shape had become adapted to habitual func- 
tion. It is upon this natural power of transformation that one 
depends for the final and complete change of the distorted bones 
to the normal; and what is true of a resistant structure like 
bone is equally true of the other constituents of the deformed 
foot. 

Age as Influencing Treatment. — There is, then, this important 
difference between the indications for treatment in infancy and 
in childhood. In the first instance the foot has no essential 
function; in the second the weight of the body and habitual use 
tend to confirm and to increase the deformity. If walking is 
permitted during the process of rectification of the foot it must 
necessarily retard its progress. As a general principle of treat- 
ment, functional use should not be permitted, therefore, until the 
weight of the body may aid rather than retard the correction of 
deformity. The great numbers of complicated and cumbersome 
machines that are described in the older text-books were designed 
for the ambulatory treatment of club-foot; and admitting that 
such apparatus may be efficacious in the hands of one skilled in 
its use, yet under ordinary conditions treatment by such means 
simply serves to fix rather than to correct the deformity. The 
most important function of the brace, aside from its use as a 
correcting appliance in early infancy, is to support the foot after 
deformity has been corrected and to guide it in its functional use 
until its normal strength has been regained. And while rectifi- 
cation of deformity, even in adolescence, by simple mechanical 
means alone is possible, yet only in exceptional cases would one 
be justified in selecting a tedious and uncertain treatment which 
offers practically no advantage over more rapid methods. 

The Rapid Correction of Deformity. — The principles on which 
operative treatment should be conducted are the same that govern 
mechanical treatment. Thus, the deformed foot must be over- 
corrected, and it must be held in the overcorrected position until 
the immediate tendency toward deformity has been overcome. 
It must then be supported until the process of transformation of 
its internal structure is completed and until the balance of mus- 
cular power has been regained. No surgical operation, however 
radical, can be, in childhood at least, curative by itself alone. 
Operative procedures are undertaken simply for the purpose of 
accomplishing the primary overcorrection, and the operation 
by which this object can be attained with the least interference 



782 ORTHOPEDIC SURGERY 

with the structure of the foot should be selected. Such an opera- 
tion is what may be called forcible manual correction. 

Forcible Manual Correction. — The patient having been anaes- 
thetized, one first attempts to correct the sharp inward twist at 
the mediotarsal joint. Supposing the left foot to be deformed, 
one grasps the heel with the right hand in such a manner that 
the projection or muscular part of the palm lies on the outer 
aspect of the foot against the most prominent part of its outer 
border, which is at the junction of the os calcis and cuboid bones. 
This hand serves as a fulcrum over which the inverted foot may 



r^^ggp^ ys 




Reduction of the varus deformity. (Lorenz.) 

be bent. The forefoot is then grasped firmly by the left hand, 
and one begins a series of outward twists over the fulcrum of the 
opposing palm, gently at first, with alternate relaxation of pressure, 
but with gradually increasing force as the resistant tissues stretch 
under the tension. 

If greater force is required, a triangular block of wood, well 
padded, may be used as the fulcrum (Fig. 510), one hand pressing 
on the heel and the other on the forefoot; but there is a great 
advantage in using nothing but the hands, because one feels 
that no injurious force is likely to be exerted. Under this steady 



DEFORMITIES OF THE FOOT 



783 



manipulation the foot soon loses its rigidity and its elastic recoil 
toward deformity; it becomes so limp that with two fingers one 
cannot only hold the sole straight, but can push it or bend it 
outward. This completes the first stage of the methodical cor- 
rection. 

One then turns his attention to the inversion of the sole, which 
makes the outer border of the foot lower than the inner border. 
The leg is grasped firmly near the ankle with the left hand, and 
with the right the foot is forcibly twisted in a direction downward, 




Flattening the sole. (Lorenz.) 

outward, and upward, over and over again, with steadily increasing 
force as the tissues slowly yield, until it may be forced into a posi- 
tion of extreme abduction, so that the sole may be made to look 
outward and downward — the reverse of the former attitude (Fig. 
422). 

One next stretches the contracted plantar fascia and reduces 
the cavus which is usually present by forcing the forefoot toward 
dorsiflexion, against the resistance of the contracted tendo Achillis, 
until the sole is made perfectly flat (Fig. 511). Finally, the 



784 



OB THOPEDIC S UB GEB Y 



fourth, and often the most difficult part of the rectification — that 
of forcing the displaced astragalus into its proper position between 
the malleoli — is attempted. To accomplish this the tendo Achillis 
is first divided subcutaneously, and, if necessary, the posterior 
ligament of the ankle is also divided at the same time. The 
patient is then turned upon his face so that with the knee resting 
on the table the leg is held upright. This allows one to hook the 
fingers about the extremity of the os calcis, while the hand and 
arm, lying along the sole of the foot, may be used as a lever to 




Reduction of the equinus deformity. (Lorenz.) 



force it toward dorsal flexion as the os calcis is drawn down- 
ward. In this manner forcible stretching is continued until the 
dorsum of the foot can be brought almost into apposition with 
the crest of the tibia. When the operation has been completed 
the foot should be perfectly limp. It is usually somewhat con- 
gested from the pressure of the fingers, but it is warm and the 
circulation is unimpaired. 

One may assume that in the transformation rigid deformity 
to yielding tissues can be moulded into the desired shape, the 
component parts of the deformed foot must have been sub- 



DEFORMITIES OF THE FOOT 785 

jected to considerable violence; that ligaments and muscles 
must have been stretched and, it may be, ruptured; that new 
surfaces are now apposed to one another in the articulations, 
and that the bones have been forced into approximately normal 
position. This method of treatment has a great advantage 
over the ordinary operative treatment in that the entire foot par- 
ticipates in the correction instead of a limited portion, as when, 
for example, bone is removed by cuneiform osteotomy. It has 
a second and almost equally important advantage in that the 




Untreated club-foot, showing the secondary knock-knee. (See Fig. 514.) ; ' !•; 

immediate use of the corrected and yielding foot is possible in 
the place of the necessary rest that must follow cutting opera- 
tions. For these reasons forcible massage should be the operation 
of choice, and preliminary, at least, to more severe procedures 
in the treatment of resistant club-foot in childhood. The only 
disadvantage of the operation is the actual labor which it neces- 
sitates on the part of the surgeon, usually twenty minutes or 
more of rather exhausting work. 

The foot must now be fixed by a plaster bandage in an over- 
corrected position. It is first evenly covered with a layer of 

50 



786 



OB THOPEDIC S UB QEB Y 



cotton, and while it is held by the assistant the plaster bandages 
are applied from the tips of the toes to the upper part of the thigh. 
It is important that the toes should not project beyond the bandage 
because of the swelling that sometimes follows. It is important, 
also, that the foot should be held in the proper position while the 
bandage is hardening, and that it should not be manipulated to 
any extent after the bandage is applied, in order that no rigid 
wrinkle may press against the skin. The bandage is applied above 
the knee in order that the tibia may be rotated outward to its 




After forcible correction. Compare with 
Fig. 513. 



The attitude of overcorrection, in which 
the feet are fixed after the operative treat- 
ment, the plaster bandage extending only 
to the knees. 



normal position and held there, and because more effective fixation 
may be assured and greater pressure exerted on the foot in walk- 
ing. To utilize this pressure to better advantage the bandage 
should be made very thick beneath the sole, and a thin foot-plate 
of wood may be incorporated in the plaster if due care is taken 
to prevent pressure on sensitive points. When the bandage is 
applied the foot should be flexed beyond the right angle, twisted 
far outward, and the outer border should be elevated considerably 
beyond the level of the inner border (Fig. 514). 



DEFORMITIES OF THE FOOT 787 

One would suppose that much pain and swelling would follow 
the operation. This is, however, not usually the case. Often, on 
the following day, the patients are able to stand upon the foot, 
and always within the first week if the bandage has been properly 
applied. The pain following this operation is far more often 
caused by pressure of an ill-fitting bandage than by the violence 
that has been used. Thus one should be careful to remove 
sections of the bandage if it appears to cause undue discomfort. 
These points are usually the front of the ankle, the back of the 
heel, and the inner border of the great toe. 

The Importance of Functional Use. — The immediate use of the 
foot is encouraged, in order that the weight of the body falling 
on its yielding structure may still further correct the deformity. 
Although only the heel and inner border bear weight directly, 
yet the pressure of the plaster sole on the parts that do not come 
in contact with the floor is usually sufficient to mould the foot 
into its proper shape. If greater pressure is thought to be neces- 
sary, wedges of wood or cork may be attached to the sole of the 
plaster bandage, so that all parts may bear weight equally. The 
bandage is covered by a stocking; a slipper may be worn in-doors 
and an ordinary' overshoe for street wear. 

The first bandage should be removed at the end of about four 
weeks, as it will have become loose. The foot will then be found 
to be extremely flexible, and by an enthusiast it might be consid- 
ered cured; but knowledge of its previous condition should make 
it evident that a much longer time will be necessary to allow 
for its consolidation in the new position. At this time almost 
no evidence of the operation remains except, it may be, slight 
discoloration of the skin. The foot is again held as far as possible 
in the overcorrected position and another plaster bandage is 
applied, usually as far as the knee only. This is allowed to remain 
for from six weeks to six months, according to the character of the 
deformity and quality of the after-treatment, it being apparent, of 
course, that the longer the foot is fixed in the overcorrected posi- 
tion the less danger of subsequent relapse. The patient uses the 
foot constantly and is drilled in the proper method of walking, 
so that the muscles of the limbs may become accustomed to the 
new and normal attitudes. 

In most instances the plaster bandage is replaced, at tie end 
of about three months, by a brace to be worn inside the shoe, 
usually of the simplest description (Fig. 531), consisting of an 
upright bar with a calf band, attached to a steel sole plate by a 



788 



ORTHOPEDIC SURGERY 



joint that will permit dorsal flexion but checks extension at a 
right angle. This is applied because the dorsal flexors, after 
years of disuse, only slowly recover sufficient power to resist the 
action of the opposing group and the influence of gravity. 

The second stage of the treatment is now begun. This may 
be divided into a period of active treatment and one of super- 
vision. The first, or treatment- 
stage, consists in massage of the 
entire leg and of the foot to stimu- 
late the growth of the atrophied 
muscles, and methodical manipula- 
tion of the foot several times a day. 
The important point in this manip- 
ulation is to force the foot with the 
hand to the extreme limit of the range 
of motions possible immediately after 
the operation, viz., eversion, abduc- 
tion, and dorsal flexion, in the same 
order as at the time of operation. 
At the same time the patient attempts 
voluntarily to carry out these motions 
with his own muscles, the power 
being supplied by the hand of the 
manipulator. Slowly the muscles 
gain in strength and ability, and 
when normal muscular power and 
balance have been regained, the 
patient is practically cured. But for 
a long period, supervision of the 
patient's attitude, of the manner of 
using the foot, of the wear of the 
sole of the shoe and the like must 
be exercised if one aims to restore its 
normal appearance and function. 
One cannot exaggerate the importance of this after-treatment, 
and of supervision at least, on the part of the surgeon. The 
active treatment may often be left to the parents. But constant 
oversight is necessary to make this after-treatment, which seems 
so commonplace and simple, effective, and to assure one's self 
that the range of motion regained by the operation does not grad- 
ually become more and more restricted, even though the contour 




\i The Taylor club-foot brace, with 
pelvic band, to prevent inward rota- 
tion of the leg. The brace is shown be- 
fore the covering and straps are applied. 



DEFORMITIES OF THE FOOT 789 

of the foot appears to be normal. Forcible manual correction may- 
be employed with advantage from the second to the tenth year, 
although the limits may be extended in either direction in special 
cases. In this operation, as described, the tendo Achillis is the 
only structure divided. There is no particular objection to subcu- 
taneous division of other tendons or ligaments in connection with 
forcible manual correction; but for such prolonged manipulation it 
is much better if the skin, which itself must be stretched, is un- 
broken and dry rather than moist from the bleeding from punctured 
wounds. For this reason it is well to correct the deformity without 
tenotomy if possible. 1 

Secondary Deformities. — In cases such as have been described 
secondary distortions of the limb are often present. Knock- 
knee rarely requires other treatment than daily manual correc- 
tion in connection with the massage of the foot and leg. Hyper- 
extension at the knee will correct itself during the treatment of 
the foot, which, being fixed in an attitude of dorsal flexion, obliges 
the patient to bend the knee habitually in walking. Inward 
rotation of the leg upon the thigh is often present. This may be 
overcome by methodical manipulation and by the use of a brace 
attached to a pelvic band (Fig. 516). 

In many instances, particularly in childhood and adolescence, 
the patient has so long walked with exaggerated outward rotation 
of the femur that after correction of the deformity no inward 
rotation of the foot appears, even though inward rotation of the 
tibia be present. In other cases the inward rotation of the foot 
is caused by a failure to completely replace the astragalus between 
the malleoli. Occasionally the tibia is actually twisted on its 
long axis, so that an osteotomy may be required in order to over- 
come the deformity. 

Malleotomy. — In confirmed club-foot, of the type under con- 
sideration, the chief obstacle to perfect correction is often the 
astragalus. This is displaced forward, downward, and inward, 
only the posterior portion of its articulating surface being con- 
tained between the malleoli. Thus the space between the two 
bones may have become insufficient for the anterior and wider 
part of the body of the astragalus. In such cases, even after 
division of the tendo Achillis and the posterior ligament of the 

1 Forcible manual correction appears to have been described first by Delore. Lorenz em- 
ploys the method supplemented in the older cases by the use of his osteoclast, to the exclu- 
sion, practically, of all other treatment. (Heilung des Klumpfusses durch das modellirende 
Redressement, Wiener Klinik, November, 1895.) For this reason it is sometimes called the 
Lorenz treatment. The method that has been described has been employed by the author 
for many years. 



790 OR1HOPED1G SURGERY 

ankle, dorsal flexion still remains restricted, and examination 
shows that the astragalus still projects as before, even though the 
foot has been forced into a position of apparent dorsiflexion and 
abduction. This apparent correction is the result of overcorrec- 
tion at the mediotarsal joint, of outward rotation of the tibia upon 
the femur, and of backward displacement of the fibula. 

In such instances the malleoli may be separated from one 
another by dividing the ligaments that hold them in apposition. 
A straight incision about two inches long is made directly over 
the anterior aspect of the articulation, the ligaments are divided, 
and by inserting a thin chisel the bones are pried apart, while 
the astragalus is replaced in the proper position. This is usually 
easy if the restraining tissues on the posterior part of the ankle 
have been divided. The wound is then closed and the foot held in 
the overcorrected position by a plaster bandage. Complete cor- 
rection of the varus deformity should, of course, precede this 
operation. 

It might seem on first consideration that if immediate correc- 
tion of deformity can be accomplished so easily in the confirmed 
cases it should be employed even in infancy. There are, how- 
ever, practical reasons against it : First, because the foot is so 
small that it cannot be easily manipulated; second, because even 
after it is corrected it must be supported until the child begins 
to walk; and third, because the foot can be so readily straightened 
without operation, which, even of so slight a character, is some- 
times the cause of much anxiety to the parents. For these reasons, 
although immediate reduction of deformity is a practicable opera- 
tion, it is usually postponed until a later time. 

Subcutaneous Tenotomy. — The division of tendons and other 
tissues by the subcutaneous method has been mentioned incident- 
ally, but as it has so long occupied an important and even at one 
time the most important place in the treatment of club-foot, the 
operation and its effects may be described somewhat in detail. 

Tenotomy, as has been stated, is performed for the purpose of 
removing an obstacle to the correction and overcorrection of 
deformity. In the acquired or paralytic form of talipes one 
or more shortened tendons may be the chief obstacles to reposi- 
tion; but in the congenital form, in which all the tissues have 
grown into deformity, the shortened tendons are by no means the 
only resistant parts, and tenotomy should be considered, there- 
fore, merely as an incident in correction. In the ordinary treat- 
ment of infantile club-foot tenotomy is usually unnecessary and in 



DEFORMITIES OF THE FOOT 791 

the great majority of cases division of the tendo Achillis is alone 
required. 

When the tendon has been divided the deformity is immedi- 
ately overcorrected; thus the two extremities are separated to 
the extent necessary to allow the improved position. At the end 
of three weeks or more, or at the time when the first plaster 
bandage is removed, the space will be filled with new material, 
and in another month the splice, which will be somewhat larger 
and thicker than the normal, should be strong enough for use. 
The slight thickening at the site of the operation may be felt for 
a year or more, but for all intents and purposes the new and 
lengthened tendon is perfectly normal, as is the function of the 
muscle of which it is a part. 

The process of repair is somewhat as follows: Immediately 
after the operation the space between the divided ends of the 
tendon is filled or partially filled with blood; then leukocytes 
appear, which, with those in the blood clot, serve as pabulum 
for the plasma cells which migrate from between the fasciculi of 
the tendon and from the tendon sheath. The fibrin and red cor- 
puscles of the clot are absorbed; the extremities of the divided 
tendon soften and become fused with the new material, which 
begins to take on the form and consistency of true tendon and 
to separate itself from the adherent sheath. This new tendon 
differs from the normal structure in that the fibrous fasciculi 
are more irregular and its substance is more like scar tissue, but 
practically it is normal in its appearance and function. 1 

Since the tendon sheath serves an important purpose in repair, 
it should be disturbed as little as possible. For this, as well as 
for other obvious reasons, subcutaneous tenotomy of the tendo 
Achillis, which is so prominent and so distinct from other impor- 
tant parts, is to be preferred; but if more extensive division of 
other tendons is required the open operation is often indicated. 

Division of the Tendo Achillis. — For this operation anaesthesia 
is usually required, preferably by means of nitrous oxide gas; and 
it is hardly necessary to state that surgical cleanliness, even in 
so slight a procedure, is essential. 

The instrument should be small and very sharp, so that no 
force is required in the operation; the blade should be as long as 
the tendon is wide. The patient is turned upon the side or to 
the prone position, so that the foot may be held with the heel 

1 R. Seggel, Beitrage zur klin. Chir., 1903, Band xxxvii., S. 342. 



792 ORTHOPEDIC SURGERY 

upward by the left hand. The position and size of the tendon 
is ascertained by careful palpation, and the knife is then inserted 
to its inner side, at about the level of the extremity of the internal 
malleolus. The flat surface of the blade is held parallel to the 
tendon, and it is passed beneath it until its point can be felt beneath 
the skin on the opposite side. The edge is then turned upward 
and the tendon, being made tense, is divided by a sawing motion 
of the knife. When the division is complete, as indicated by 
the separation of the divided ends, the knife is withdrawn, and 
the minute opening in the skin, from which there is usually slight 
bleeding, is covered with a pledget of aseptic cotton. The foot 
is forced into dorsal flexion and is securely fixed by a plaster 
bandage. In applying the dressing one should take care that 
no pressure is brought upon the seat of operation, as this might 
interfere with the effusion of plastic material. As soon as the 
discomfort attending the operation has subsided the patient is 
encouraged to stand and to walk. Functional use stimulates the 
circulation, and, far from retarding repair, it is in my experience 
an important agent in assuring firm and rapid union. 

The Open Method. — The tendon may be exposed by a long 
vertical incision; it is then split for a distance of two or three 
inches, and the division is completed at the upper and lower ends. 
The two halves are then allowed to slide by one another until 
the necessary elongation has been obtained. These are then 
sutured to one another. 

Theoretically, this operation, which assures union at a point 
of selection, is safer than the subcutaneous method, in which the 
ends of the tendon are separated from one another; practically, 
it is in this class of cases less satisfactory in its results than the 
subcutaneous method. 

Division of the 'plantar fascia is often necessary. The tenotome 
is inserted beneath the skin at about the centre of the concavity 
to one or the other side of the central band of the fascia, which is 
divided by a sawing motion of the knife. The part is put upon 
the stretch, and other resisting bands to the outer and inner side 
are divided in the same manner; the cavus is then corrected by 
manual or instrumental force. 

Division of the tibialis anticus is not often necessary, as this 
tendon offers little resistance to the rectification of deformity of 
the ordinary type. 

The tendon of the tibialis posticus may be divided together 
with that of the tibialis anticus near the points of attachment. 



DEFORMITIES OF THE FOOT 793 

If the operation is required it may be combined with simulta- 
neous section of the calcaneonavicular ligament, with which are 
blended the anterior part of the deltoid and fibres of the anterior 
ligament of the ankle. According to Parker's directions, the foot 
should be strongly abducted to make the parts tense. The teno- 
tome is entered directly in front of the anterior border of the internal 
malleolus, its cutting edge being turned forward between the skin 
and the ligament. It is then turned toward the ligament, and 
the tissues are divided to the bone. The blade is then made to 
enter the interval between the astragalus and the scaphoid, and 
is carried downward and forward to divide the inferior part of 
the ligament and at the same time the tendons of the tibialis 
anticus and posticus. 

The posterior ligament of the ankle-joint may be divided or 
sufficiently weakened so that it may be ruptured after section of 
the tendo Achillis by passing the knife directly downward in the 
middle line upon the upper border of the astragalus. 

The Correction of Confirmed Club-foot by the Method of 
Julius Wolff. 

Wolff's treatment of club-foot, as described by Freiberg, a 
former assistant in his clinic, may be summarized as follows: 1 
The patient is anaesthetized, and with the hands and by the use 
of a moderate amount of force the deformity is reduced as far as 
possible. The foot is held in the improved position by means of 
strips of. adhesive plaster passing from the dorsal surface of the 
inner border of the foot under the sole and up to the outer aspect 
of the leg. The leg and foot are then covered with cotton from 
the tuberosity of the tibia to the tips of the toes, and a plaster 
bandage is applied. As the plaster is hardening the position of 
the foot is still further improved by pressing the heel inward and 
the forefoot outward and upward. Two fenestra are cut in the 
plaster at the points of greatest pressure — one over the external 
surface of the ankle and the other over the internal surface of 
the great toe. If tenotomy is considered necessary it is usually 
performed as a preliminary operation several days before forcible 
correction. 

On the third or fourth day after the operation a wedge-shaped 
section is cut from the bandage on the outer side of the ankle- 
joint and a linear division is made about the ankle, so that the leg 

1 Medical News, October 29, 1892. 



794 



ORTHOPEDIC SURGERY 



and the foot parts of the bandage are separated (Fig. 517). The 
leg being held firmly, the foot is forced outward and upward to 
the extent that the wedge-shaped opening on the plaster will 
allow, and the two sections are then united by a covering of plaster 
bandage. For the secondary correction anaesthesia is not required. 
At intervals of several days larger wedges are removed, and the 
manipulation is repeated until the patient stands with the foot 
in a satisfactory attitude; that is, in pronation, abduction, and 
dorsiflexion. If the deformity is extreme the bandage may be 
reapplied before the correction is com- 
pleted with advantage. One should take 
care that the toes are not compressed, but 
lie on the same plane in normal relation 
to one another. 

When rectification is complete the plaster 
bandage is covered with strips of pine shav- 
ings, held in place by a crinoline bandage, 
and painted with carpenter's glue. When 
this is hardened the whole is covered with a 
thin silicate bandage; over this the shoe is 
fitted and the patient is encouraged to walk. 
This form of dressing is used until the trans- 
formation of the deformed parts may be sup- 
posed to be complete, the time varying with 
the case, from a few months to a year. The 
time required for the primary correction is 
from a week to a month. When the "bandage 
is finally removed massage and exercises are 
to be employed. 1 Wolff's treatment is an efficient means of correc- 
tion, although somewhat tedious. It may be more conveniently em- 
ployed in later childhood and adolescence than at an earlier age. 




The points at which the 
bandage is divided and the 
wedge removed. (Freiberg.) 



Forcible Correction of Deformity by Means of Osteoclasts 
and Wrenches. 

In place of manual correction greater force may be employed 
by means of wrenches or osteoclasts to overcome the deformity. 
There is this important difference between the two procedures: 
force may be applied by the hands for as long a time as is necessary 
without fear of injury, while force applied by a machine must be 



1 Ueber die Ursachen, das Wesen und die Behandlung des Klumpfus 
Berlin, 1905. 



Julius Wolff, 



DEFORMITIES OF THE FOOT 



795 



momentary because of the pressure and strain on the parts where 
the leverage is exerted. Manual force continuously applied may 
be supposed to stretch the resistant parts, and although much 
less power is exerted it is really more effective than the sudden 
and momentary force of the wrench or osteoclast, because it 
may be continued until the deformity has been overcorrected, 
while complete correction by means of instruments may neces- 
sitate several operations. 




A \ 



wk . * . . 


1 


• 



The Thomas wrench as used in the 
correction of club-foot. 



Resistant club-foot in later childhood. 
(See Fig. 521.) 



The Thomas Method.— Of instrumental correction that by 
means of the Thomas wrench is one of the simplest and most 
efficient. The wrenching may or may not be preceded by ten- 
otomy, a point to be decided by the resistance of the parts. As 
a rule, division of the tendo Achillis alone is necessary. The 
instrument is a simple heavy monkey-wrench, of which the jaws 
have been replaced by two strong pins slightly bulbous at the 
ends to keep the covers of rubber tubing from slipping off. 



796 ORTHOPEDIC SURGERY 

The wrench is applied to the inner side of the foot and screwed 
down so that it may "bite" and hold its place firmly, for if it 
slips it is likely to abrade or tear the skin; then with consider- 
able force the foot is twisted outward and upward (Fig. 518). 
The "keynote" of the operation is to so wrench the foot that 
it loses its elasticity and shows no tendency to recoil toward defor- 
mity. The foot is then placed in the best possible position, and 
is retained there by the Thomas foot splint or by a plaster bandage. 
In certain instances one may complete the rectification at one 
operation, but this is not usually attempted, the procedure being 
repeated at intervals of a few days until the deformity has been 
overcorrected. In very resistant cases eight or ten applications 
of force may be necessary. When the deformity has been rec- 
tified the foot is held in the overcorrected position for several 
weeks by the splint or by the plaster bandage. 

As a walking appliance a simple upright of iron with a calf 
band is applied to the inner side of the leg, from a point just 
below the knee to the heel of the shoe into which it is inserted, 
as is the Thomas knock-knee brace (Fig. 376). By bending the 
upright the foot may be held in slight valgus, and this position 
is still further assured by making the outer side of the sole of 
the shoe thicker than the inner, so that the weight falls upon the 
inner border of the foot. In many instances the walking brace 
may be dispensed with in the after-treatment, but a light brace 
is usually worn to hold the foot in the corrected position during 
the night, until the power of the abductors and dorsal flexors has 
been regained. Massage and manipulation are used in the after- 
treatment in the manner already described. 

When properly applied the treatment is satisfactory and free 
from danger. Sloughing of the tissues caused by the pressure 
of the instrument or by the plaster bandages has been reported, 
but such accidents have not occurred in the extensive practice of 
Thomas and Jones. 

Correction by Means of the Osteoclast.— The late Mr. 
Grattan, of Cork, used the osteoclast that goes by his name 
(Fig. 380) to crush and to overcorrect resistant club-foot. The 
operation may include besides the correction of the deformity of 
the foot itself, fracture of the leg above the malleolus, to turn the 
foot toward valgus, and a second fracture half-way up the leg, 
to overcome the inward rotation or twist of the tibia. Mr. 
Grattan 's results have been very satisfactory. Other appliances 
constructed on somewhat similar principles may be employed. 



DEFORMITIES OF THE FOOT 



797 



Of these the Lorenz osteoclast 1 and the Bradford 2 lever apparatus 
are the most effective. 

The Open Incision Combined with Forcible Rectification of 
Deformity. Phelps' Operation. — When extensive division of 
contracted parts is indicated the open incision is to be preferred 
because of the opportunity thus offered for the recognition and 
for intelligent selection of structures that require division in the 
final correction of the deformity. 

Phelps' operation is essentially simply the division of resistant 
parts through an incision on the inner border of the foot, com- 
bined with sufficient force, manual or instrumental, to overcorrect 




Illustrating the correction of the left foot by Phelps' operation. 

the deformity. It is the most conservative of the more radical 
procedures, and by it even the most severe type of deformity in 
the adult can be corrected; that is to say, the deformity may be 
overcome and a serviceable foot may be assured to the patient. 
Perfect functional cure is not possible when deformity has been 
confirmed by many years of neglect. 

The steps of the Phelps' operation are as follows : After proper 
surgical preparation the Esmarch bandage is applied. The tendo 
Achillis and usually the posterior ligaments of the ankle are 
divided subcutaneously, and by manual or instrumental force 



Wiener Klinik, November, December, 1895. 



Bradford and Lovett, 2d ed., p. 414. 



798 



ORTHOPEDIC SURGERY 



one attempts to correct the plantar flexion. An incision is then 
made on the inner border of the foot, just below and in front of 
the internal malleolus, which is extended directly downward over 
the head of the astragalus to include the inner quarter of the sole. 
Through the incision all resistant parts are divided in order, as 
stated by Phelps. 

1. The tibialis posticus, and the anticus if it offers resistance. 

2. The abductor hallucis. 

3. The plantar fascia. 

4. The flexor brevis digitorum. 

5. The long flexor of the toes. 

6. The deltoid ligament in all its branches. 




The left foot (Fig. 519) corrected by Phelps' operation and by cuneiform osteotomy 
of the os calcis. 

During the successive division of the tissues repeated attempts 
are made to correct the foot, and only those structures are divided 
that present themselves as tense and resistant tissues when the 
foot is forcibly abducted. 

In the adult type of club-foot no particular effort is made to 
recognize the different structures, but all the tissues on the inner 
side of the foot, including bloodvessels and nerves, the deep liga- 



DEFORMITIES OF THE FOOT 



799 



merits, and occasionally the tendon of the peroneus longus muscle, 
are divided. Even then it is necessary to apply considerable 
force to correct the deformity. In certain instances the recti- 
fication of deformity necessitates osteotomy of the neck of the 
astragalus or the removal of a cuneiform section from the os calcis. 
The object of the Phelps operation is, by division of resistant 
tissues and by the use of force, to overcorrect the deformed foot 
at one sitting, and as much force and as extensive division of 




Resistant club-foot in later childhood. (See Fig. 523.) 



tissues as are required to accomplish this object should be employed 
by the operator. 

When the foot can be held in the desired position without 
resistance the wound is covered with Lister protective, the foot 
and leg are thickly covered with gauze and cotton, a plaster 
bandage is applied, and the limb is elevated. The large, gaping 
wound closes by granulation in from one to three months. The 
first bandage is usually changed at the end of one or two weeks, 
and the patient then begins to bear weight on the foot. 

By this operation the foot, even in severe cases in adult life, 



800 OB THOPEDIO SURGERY 

may be made straight in appearance. It is evident, however, 
that in such cases the correction of the deformity of the bones is 
by no means always perfect, for the forefoot may be simply 
twisted outward and upward, while the astragalus and os calcis 
may remain in an approximation to their original deformity. 
After thorough overcorrection by the Phelps operation the danger 
of recurrence of deformity in the adult and adolescent type of 
club-foot is not great, and in many instances support other than 
that of the plaster bandage for several months after the operation 
may be unnecessary; but in childhood the ordinary precautions 
in after-treatment to prevent relapse will be necessary. 

Operations on the Bones. 

Osteotomy of the neck of the astragalus, as a supplementary 
part of the operation of forcible correction, has been mentioned. 
In certain instances, particularly in the adolescent or adult type 
of deformity, the displaced astragalus may offer such an obstacle 
to correction that its removal is indicated — an operation first 
performed by Mr. Lund, of Manchester. 

Astragalectomy. — The astragalus, which in club-foot is displaced 
forward, may be removed easily by means of an incision passing 
over its most prominent part, in a direction forward and down- 
ward from the tip of the external malleolus, between the tendons of 
the peroneus brevis and tertius. The soft parts are drawn aside, 
the ankle and astragalonavicular joint are opened, and the attach- 
ments to the navicular, and, as far as possible, those at the inner 
and outer border, are divided. The foot is then adducted so 
that the head of the bone may be seized with forceps and drawn 
upward, the interosseous ligament and the internal lateral liga- 
ment having been divided with curved scissors, the astragalus 
is removed. If after removal of the astragalus the deformity 
cannot be corrected, the anterior part of the os calcis or the 
external malleolus should be removed as well. A useful movable 
foot may be obtained by this operation, but it by no means assures 
the patient from recurrence of deformity. It is never indicated 
as a primary operation, in childhood at least. The varus should 
be thoroughly corrected as a preliminary procedure, for until 
then the resistance that the astragalus offers to dorsal flexion 
cannot be accurately estimated (Fig. 523). 

Cuneiform Osteotomy. — The removal of cuneiform sections 
of bone from the outer border of the foot is sometimes indicated 



DEFORMITIES OF THE FOOT 



801 



when the deformity is of long standing, but the operation should 
be secondary to other methods of correction. The aim should be 
to lengthen the contracted and shortened tissues on the inner 
border of the foot to the extent required for reposition, not to 
remove bone to accommodate these shortened tissues. If this 
has been shown to be impossible by ordinary means, then re- 
moval of bone may be indicated; but it is not often necessary in 
childhood or even in adolescence. If sufficient bone is cut away 
from the adult foot to permit complete correction of the defor- 




After forcible correction and astraga- 
lectomy. (See Fig. 523.) 



Partially corrected club-foot, showing 
secondary knock-knee. 



mity, relapse is not usual; but in childhood, as has been stated, 
no operation will take the place of after-treatment. 

The treatment by cuneiform osteotomy as it is ordinarily car- 
ried out is sufficiently simple. In severe cases the astragalus is 
usually removed, and a wedge-shaped section of bone is taken from 
the os calcis, cuboid, and, if necessary, it may include the navicular 
bone also. The external malleolus may be removed if it inter- 
feres with reposition. Preliminary fasciotomies and tenotomies 
are usually performed, but those who favor this method of treat- 

51 



802 ORTHOPEDIC S URQEB Y 

ment rarely use force in reposition. If the deformity is less 
marked the astragalus is not removed, but a part of its body and 
neck are included in the cuneiform resection. The foot is retained 
in proper position until the wounds are closed; then plaster 
bandages are employed for several months. Braces are seldom 
used in the after-treatment. 

Secondary Osteotomy. — In certain cases of relapsed or in- 
effectively treated club-foot, even in childhood, deformity of the 
os calcis interferes with correction of the foot. In such instances 
the removal of a cuneiform section of bone from the anterior 
extremity, may be of service. Osteotomy of the tibia may be 
required in cases of persistent inward rotation. 

Simple Mechanical Rectification of Deformity in Walking 
Children and in Later Years. 

It has been stated that simple mechanical rectification of de- 
formity was possible even in adolescence, but that the time re- 
quired for such treatment, usually extending over several years, 
as a rule, excluded it from consideration. 

The simplest mechanical treatment is that by which the foot is 
slowly forced from equinovarus into equinovalgus by a brace on 
the lever principle, which is at first shaped to the deformity, and 
is then gradually straightened as the resistance diminishes. When 
the midpoint has been passed between varus and valgus the 
weight of the body aids in the correction of the remaining varus 
and equinus. The modification of the Taylor brace used by Jud- 
son, an advocate of pure mechanics in the treatment of club-foot, 
will serve to illustrate the type of apparatus which, with slight 
change, may be employed to correct or to support the weakened 
or deformed foot. 

The brace consists of an upright, a flat, tapering bar of mild 
steel, a foot-plate of steel from 18 to 16 gauge, and a strong calf 
band. The shape of the brace, the method of its attachment to 
the leg by straps of webbing, and its effect in gradually changing 
the attitude of the foot from varus to valgus are shown in the 
accompanying figures. 

The upright is firmly riveted to the foot-plate in the angle of 
deformity, so that the patient must walk upon his toes; as the 
equinus is decreased by the influence of the weight of the body 
this angle is lessened (Figs. 527 and 531). 

The important points are that the brace shall be strong enough 



DEFORMITIES OF THE FOOT 



803 



to hold its place under the strain of use and that the foot shall 
be firmly secured to it, whether one or many straps of webbing 
are required, as may be seen in the figures. The use of massage 
and manipulation is, of course, combined with the mechanical 
treatment. 

By persistent attention to the details of treatment satisfactory 
results can be obtained occasionally by this method in the less 
resistant cases, even in adolescence. 



Q 





The Judson brace. Fig. 525 shows the construction of the brace; the foot-plate, with 
internal flange or "riser," the upright riveted to it, and the calf band. Fig. 526 shows the 
brace adjusted to fit the deformed foot. 



Recapitulation of the Principles of Treatment of Congenital 
Talipes Equinovarus.— The object of treatment is to overcome 
and to overcorrect the deformity at as early a period of life as 
is possible, and as quickly as possible. The object of overcorrec- 
tion is to overcome all the resistance of the tissues that may even 
in the slightest degree limit the normal range of motion in any 
direction. The foot must be fixed in the overcorrected posi- 
tion until the recoil of the tissues toward deformity is no longer 
present. 

It must be supported in the proper relation to the leg, and 
at a right angle with it, until the muscular balance has been 
re-established by stimulation of the weaker and by limitation of 



804 



ORTHOPEDIC SURGERY 



the activity of the stronger muscles, and until transformation of 
the internal structure has been completed. 

If efficient mechanical treatment is applied at the proper time 
— that is to say, in earliest infancy — no operation other than 
division of the tendo Achillis will be required. 

If the deformity is not corrected or is but partially corrected 
when the child begins to walk, some form of operation is, as a 
rule, indicated; but division of the resistant tissues must always 




Showing the progressive reduction of deformity. Fig. 527 shows the ordinary attitude of 
the neglected club-foot in childhood with the adjustment of the brace, it being bent to 
accommodate the deformity. Fig. 528 shows additional details— an upright spur, useful in 
holding the heel and for the attachment of straps; the spur of sheet brass that may be bent 
over the great toe to hold it in position. Fig. 529 shows other details in the method of 
attachment, a strip of adhesive plaster, with two tails in the place of the band of webbing. 
This aids in fixing the heel. (See Figs. 530 and 531.) 



be combined with the employment of sufficient force to accom- 
plish the desired result, viz., overcorrection of the deformity. 
Forcible manual correction, applied in the manner described, is 
the most efficient means of attaining this object. No instrument 
can equal the hand. The force that can be applied by the hand 
is sufficient for the correction of all the ordinary cases in early 
childhood, and, in combination with subcutaneous division of the 
more resistant tendons and ligaments, even in later childhood and 
adolescence. 



DEFORMITIES OF THE FOOT 



805 



Forcible correction by the Thomas wrench under the same 
conditions is an efficient treatment, but there is a manifest disad- 
vantage in submitting a patient to a succession of operations, 
even of so slight a character, if immediate overcorrection can be 
attained by other means. 

The Phelps operation, which combines thorough division of the 
resistant parts with the application of sufficient force to overcorrect 
the foot, is the operation of selection for the more resistant cases 
in adolescence, in adult life, and in extremely resistant cases in 
childhood. 

Fig. 530 Fig. 531 




Showing the progressive reduction of deformity and illustrating the process of changing 
the shape of the brace from time to time until it holds the foot in valgus. (See Fig. 527.) 

Astragalectomy and cuneiform osteotomy are never indicated 
as primary operations, but one or the other may be necessary for 
the complete rectification of the deformity when other means have 
failed. 

Complete cure of deformity, even in the later years of child- 
hood, is possible by means of braces alone, but such treatment is 
very tedious. It requires the continuous supervision of the skilled 
orthopedist, as well as the intelligent and persistent co-operation 
of the parents. The results are in no way superior to those 



806 ORTHOPEDIC SURGERY 

attained by more rapid methods, while the disadvantages of long 
continued use of braces are sufficiently obvious. To the popular 
faith in braces as a cure-all of deformity, and to the unintelligent 
use of braces, may be ascribed now, as in former times, the 
greater number of failures in treatment of this eminently curable 
deformity. On the other hand the belief, so prevalent among 
physicians, that a radical operation, if it does not absolutely 
assure a cure, is, at least, the essential part of the treatment is 
equally falacious. 

Rectification of deformity, by whatever means, simply com- 
pletes the first stage of treatment. Perfect cure can only be 
assured by attention to the small details of after-treatment, by 
checking the slightest impulse toward deformity, and by guiding 
the unbalanced foot toward normal functional use. 



Other Varieties of Congenital Talipes. 

Forms of congenital distortion of the foot other than equino- 
varus are not uncommon; but, as a rule, these deformities are so 
slight and, as compared to equinovarus, so easily remedied that 
they are relatively of b'ttle importance. This distinction does 
not apply, however, to acquired talipes, which will be considered 
in the succeeding chapter. 

Congenital Talipes Varus. — Eighty-nine cases of simple varus 
are recorded in the table of statistics in a total of 2103 congenital 
deformities of the foot. 

This deformity often appears to be an incomplete form of 
equinovarus, but in some instances there is simply a slight inward 
twist of the foot without supination (Fig. 470). In some cases of 
this character, the forefoot is apparently drawn inward by the 
active movement of the great toe, which, . in such cases, seems 
almost prehensile. (See Pigeon-toe.) In the more marked form 
the foot is adducted and supinated, and the tissues are very re- 
sistant. 

The slight grades of deformity may be treated by simple manip- 
ulation, and if distortion persists after the first year the shoe 
will, as a rule, correct it. The more marked varieties must be 
treated like the varus deformity of ordinary club-foot, by braces 
or by the plaster bandage, until the varus has been transformed 
into valgus. The after-treatment is the same as that for ordinary 
club-foot. 



DEFORMITIES OF THE FOOT 807 

Congenital Talipes Equinus.— This is a rare congenital 
deformity, about half as common, according to the statistics, as 
varus (49 cases in 2103). The term equinus implies that dorsal 
flexion is limited, but that the foot is not deviated to one or the 
other side (toward valgus or varus). In congenital equinus the 
deformity is, as a rule, slight, and in many instances it may be 
overcome by gentle manual force applied frequently. In the 
more resistant type mechanical correction or tenotomy, followed 
by overcorrection and support, may be necessary. i 

Congenital Talipes Calcaneus.— Congenital calcaneus is com- 
paratively rare (47 cases in 2103). As a rule, the heel is promi- 
nent, the foot is habitually dorsiflexed, and the dorsum can 
be easily brought into contact with the crest of the tibia (Fig. 
485). The exaggerated cavus that is usually present in acquired 
calcaneus is absent. Occasionally the deformity is accompanied 
by hyperextension of the knee; and if, as in many instances, there 
is a history of breech presentation, it may be inferred that the 
attitude before birth was one of extreme flexion of the thighs 
upon the abdomen, the anterior surfaces of the extended legs 
being pressed closely to the ventral surface of the body, the feet 
being fixed in an attitude of dorsiflexion. As a rule, the defor- 
mity is slight, and the resistance of the tissues on the anterior aspect 
of the leg can be easily overcome by massage and manipulation. 
The foot should be gently forced toward plantar flexion several 
times in the day, and the weak muscles of the calf should be 
stimulated by massage. 

Cure may be hastened by the use of some simple form of reten- 
tion splint to hold the foot in plantar flexion until the posterior 
group of muscles has recovered its power. Tenotomy or other 
operative treatment is not often required. 

In rare instances the tibia may be bent slightly backward, 
thus increasing the deformity. In such cases the distortion of 
the bone may be overcome by manipulation and by apparatus. 

Congenital Talipes Valgus. — Congenital valgus (Fig. 486) is 
somewhat more common than the preceding varieties (144 in 
2103). Not infrequently it is combined with a slight degree of 
calcaneus or equinus. The resistance of the contracted tissues 
is not great, and the deformity may be overcome, in most cases, 
by persistent manipulation. If the muscular power is sufficiently 
unbalanced to warrant it the foot should be fixed in the over- 
corrected position (varus) for a time. 

Congenital valgus is one form of what is known as weak 



808 



OB THOPEDIC S UB GEB Y 



ankle, and it frequently passes unnoticed until the child begins 
to walk. If at that time, in spite of massage, the muscles appear 
weak or if the foot inclines outward when weight is borne it is 
well to make the sole of the shoe wedge-shaped, the thicker part 
(one-quarter of an inch) on the inner side. In more persistent 
cases a brace may be necessary, as described in the treatment of 
the acquired variety. (See Weak Foot.) 

Talipes Equinovalgus is less common (35 in 2103). This must 
be treated as the other varieties by complete overcorrection of 




Congenital calcaneovalgus. 



deformity, manual or otherwise, and by subsequent massage 
and support if necessary. 

Calcaneovalgus (87 in 2103), Calcaneovarus (10 in 2103), 
Equinocavus (1 in 2103), Valgocavus (1 in 2103), Cavus (5 in 
2103), are extremely rare, as indicated by the statistics. If treated 
early by persistent massage supplemented by retention apparatus, 
these, as well as nearly all slighter grades of congenital defor- 
mity, may be corrected and cured even before the child begins 
to walk. 



DEFORMITIES OF THE FOOT 



809 



Congenital Deformities of the Foot Associated with 
Defective Development. 

Talipes Equmovalgus Associated with Congenital Absence 
of the Fibula. — This is a rare deformity, but the most common of 
this class. The foot at birth is usually in an attitude of well- 
marked and resistant equino valgus. The leg is somewhat shorter 
than its fellow, and the tibia is often bent sharply forward, some- 
times to an acute angle, at a point somewhat below the centre, as 

Fig. 533 




Congenital equinovarus, with deformity of the great toes. 



if it had been broken. At the most prominent point the skin 
may be adherent or it may present a dimpled appearance. In 
some instances the formation of the foot is perfect, but more 
often one or more of the outer toes, with the corresponding meta- 
tarsal bones, are absent (Fig. 534). 

Statistics. — Haudek collected from the literature 97 cases. Of 
these 46 were in males, 21 were in females, and in 30 the sex 
was not recorded. In 67 (69 per cent.) there was total absence of 
the fibula. In 30 the defect was partial; of the lower extremity 
of the fibula in 17, of the upper extremity in 9, and of the middle 



810 



ORTHOPEDIC SURGERY 



Fig. 534 



in 2 cases. In 27 cases both fibulae were absent or defective; 
in 68 one only — the right in 31, the left in 25, and in the others 
the side was not recorded. In 61 cases toes were lacking, and 
in these cases it may be inferred that the corresponding meta- 
tarsal bones were absent also. 
The fourth and fifth toes were 
absent in 27 cases; the little toe 
alone was missing in 15. In 
many instances, as is usual in 
cases of defective development, 
deformity of other parts was 
present; for example, in 17 in- 
stances the patella was absent or 
undeveloped and in 11 the upper 
extremities were defective. 1 

Etiology.— The cause of de- 
formity, associated with absence 
of bone, may be either an origi- 
nal defect in the germ or it may 
be due to interference with 
its development. In some in- 
stances amniotic adhesions may 
be one of the predisposing 
causes; the sharp bend in the 
tibia, so often present, may be 
due to the lessened resistance 
of the defective part. 

Treatment. — The indica- 
tions for treatment are to cor- 
rect the deformity of the foot in 
the usual manner. The bend 
in the tibia may be straightened 
by manipulation and splinting, 
or by osteotomy if necessary. 
When the patient begins to walk 
the foot must be supported. A 




Defective formation of the lower limb, illus- 
trating progressive disproportion. 



light steel upright on the outer side of the leg, provided with a 
T-strap to hold the leg against it, will supply the place of the 
missing fibula. As the growth of the tibia, and in less degree that 

1 Cotton and Chute, Boston Medical and Surgical Journal, 1898, Nos. 8 and 9 (128 cases). 
Mazzitelli, Arch. Ortopedia, 1898, F. 5. Boinet, Revue d'Orthop^die, November, 1899. Vide 
also Emil Hain (113 cases), Archiv. Orthop. Mechanicotherapie und Unfal Chir., 1903, Bd. i. 
H. 1. 



DEFORMITIES OF THE FOOT 811 

of the femur, is retarded a final shortening of three or more inches 
may be expected, but with care a useful limb may be assured. 

Talipes Varus or Equinovarus Associated with Congenital 
Absence of the Tibia. — Defective formation of the tibia is much 
less common than that of the fibula. Myers 1 has collected 46 cases . 
Of the 38 cases in which the sex was recorded, 25 were in males and 
13 in females. In 31 instances the defect was of one side; in 17 both 
tibiae were defective. In most of the cases the femur was somewhat 
shortened and its lower extremity was imperfectly developed. In a 
third of the cases the patella was absent, and in many instances 
other malformations were present. In nearly all the cases there was 
flexion contraction at the knee and the fibula was dislocated back- 
ward. The foot is practically always in an attitude of varus. The 
toes may be normal, but in a number of instances the great toe 
is lacking. In possibly a third of the cases a portion of the tibia, 
usually the upper extremity, is present. 2 

The prognosis as regards a useful limb is extremely bad. The 
growth of both the thigh and the leg is much retarded, and it is 
almost impossible to balance the foot upon the fibula by any form 
of brace. 

The ordinary treatment, after the correction of the deformity 
of the foot, has been to resect the extremities of the femur and the 
fibula to induce anchylosis. No final results have been reported, 
but it may be assumed that an artificial limb would provide a 
more useful support than the short and distorted extremity. 

Congenital Deficiency and Hypertrophy.— The leg bones may 
be perfectly formed, but one or more bones of the foot itself may 
be absent. In these cases, after the reduction of the deformity, 
a support to hold the defective foot in its proper relation to the 
leg must be used. 

The foot may be divided into two parts, so that it resembles a 
lobster claw. Supernumerary toes, or deficiency of toes, or hyper- 
trophy of one or more of the toes, with or without corresponding 
overgrowth of the foot or leg, are not extremely uncommon. 

These deformities must be treated on ordinary surgical prin- 
ciples. 3 

1 Medical Record, July 15, 1905. 

2 Lanois and Kuss report 40 cases. Revue d'Orthope'die, November, 1901. 

3 Ueber missbildungen der Menschilichen Gliedmassen und ihre entstehungsweise, Klaus- 
ner, 1900. 



812 ORTHOPEDIC SURGERY 



Constricting Bands. 

Tightly constricting bands of scar-like tissue, accompanied by 
deep indentations in the flesh of the foot or leg, are sometimes 
seen. These are supposed to be caused by amniotic adhesions. 
"Spontaneous amputations" of toes or of the foot itself are due 
to the same cause (Fig. 489). 

In ordinary cases the bands require no treatment, but if they 
interfere with the nutrition of the foot they may be removed. 

Congenital (Edema of the Feet. 

In rare instances, sometimes in combination with deformity, 
the tissues of the feet appear to be cedematous, although the circu- 
lation seems to be perfect. The condition is apparently due to 
obstruction of the lymphatic circulation. 

It should be treated by massage and by compression. 

Spina Bifida and Talipes. 

Talipes with spina bifida should be treated as are other forms 
of club-foot. If paralysis of the lower extremities be present, 
as is often the case, the corrected feet must be supported as in 
the ordinary forms of paralytic deformity. 1 



CHAPTER XXIII. 

DEFORMITIES OF THE FOOT (Continued). 
Acquired Talipes. 

In the account of the congenital deformities of the foot it was 
stated that the form known as equinovarus was by far the most 
common, and that as compared with it the other deformities were 
of slight importance. 

In the acquired varieties of talipes the equinovarus deformity 
is much less common, the proportion in the congenital form being 
77.4 per cent, and in the acquired 30 per cent, of the total num- 
ber. Acquired equinus comes next in frequency, 25.9 per cent, 
as compared with 2.3 per cent, of the congenital deformity; and 
every variety and combination of distortion finds its representa- 
tive in acquired talipes, as may be seen in the tables. (See page 
761.) 

Etiology. — The cause of acquired talipes is almost always 
paralysis. In the table of statistics it will be seen that in 79.9 
per cent, the paralysis was of spinal origin (anterior poliomyelitis). 
In 11.5 per cent, it was cerebral, the talipes being a part of the 
deformity of hemiplegia or paraplegia. In a few cases the de- 
formity was caused by local disease or by local paralysis, and 
the remainder, or 7 per cent., were of traumatic origin. 

The distinction between the two varieties of talipes, congenital 
and acquired, has already been emphasized. In the congenital 
form the deformity is the essential disability, for when deformity 
has been rectified the most difficult part of the treatment has 
been accomplished and perfect cure may be expected. In the 
acquired form the straightening of the foot is but a preliminary 
part of the treatment, for cure is not to be expected except in 
that small proportion of cases in which the primary disease of 
the spinal cord has caused no permanent injury to its structure, 
or in which the deformity was the result of some slight or pass- 
ing disability or of disease or injury. Congenital talipes cannot 
be anticipated or prevented, Acquired talipes is an effect of par- 
alysis only when protective treatment has been neglected. It is a 



814 ORTHOPEDIC SURGERY 

result, therefore, that may be foreseen, and thus, by proper treat- 
ment, prevented. 

Development of Deformity. — The characteristics of anterior 
poliomyelitis are described elsewhere. (Chapter XVII.) In its 
effect upon the foot the usual sequence is somewhat as follows: 
At the onset the paralysis is usually widespread, affecting an 
entire limb, for example; then follows a period of partial recovery, 
after which the amount of damage that the spinal cord has sus- 
tained may be estimated. It is during the period of partial 
recovery, the six months or more following the attack, that deform- 
ity develops. If, for example, the anterior group of leg muscles 
is paralyzed, the foot habitually hangs downward, an attitude 
induced by the force of gravity and by the contraction of the 
unaffected posterior group. If it is allowed to persist the tissues 
accommodate themselves to the new position; the active mus- 
cles which are never extended to their normal limit become struc- 
turally shortened, while the weakened or paralyzed muscles 
are correspondingly overstretched. Even within a few weeks 
after the onset of the paralysis the evidences of progressive de- 
formity are plain. The contracted tissues resist passive motion 
in the directions opposed to the habitual attitude, and the child 
shows evidence of pain if force is used to increase the limited 
range of motion. As has been stated already, acquired talipes 
is an unnecessary deformity. It may be prevented by support- 
ing the paralyzed part in a right-angled relation to the limb, 
and by systematic passive movements throughout the entire range 
of normal motions. 

Anterior poliomyelitis is most common during the second year 
of life, or when the child has already begun to walk. When the 
first or more general effect of the disease has passed away the 
child again uses the disabled limb as best it may; thus the dis- 
tortion of the foot is increased and confirmed by the weight of 
the body and by functional use in the abnormal attitude. 

The final deformity, in a particular case, can be predicted from 
a knowledge of the function of the muscles which have been dis- 
abled. For example, paralysis of the tibialis anticus, the most 
powerful dorsiflexor and invertor of the anterior group, must 
result in equino valgus. If the peroneus brevis and tertius are 
affected varus will follow. Paralysis of the calf muscles will 
cause calcaneus. Paresis or paralysis of the entire anterior group 
will cause equinus. If all the muscles are paralyzed, what is 
called a dangle-foot is the result; the cold, atrophied member 



DEFORMITIES OF THE FOOT 815 

dangles with but little tendency to deformity unless it is capable 
of use, when it is usually forced into an attitude of varus or 
valgus. 

A slight degree of paralysis may cause so little immediate 
disability that it may be overlooked, and yet it may be sufficient 
to induce disability or deformity even, in later years. This fact 
has been mentioned in the etiology of the contracted foot. 

Differential Diagnosis between Congenital and Acquired 
Deformity. — The history itself usually indicates the etiology, for 
deformity of the foot at birth is never overlooked by the mother. 
Acquired talipes is of slow development, and it is practically 
always preceded by disease, weakness, or injury. 

In paralytic talipes (anterior poliomyelitis) there is evidence of 
paralysis in loss of function of certain muscles, as shown by elec- 
trical stimulation or by pricking the foot with a pin; later, in the 
atrophy of the muscles and often in the evident change in the 
nutrition and diminished growth of the limb. 

Only in neglected and extreme cases of talipes in the adolescent 
or adult could there be difficulty in distinguishing between the 
acquired and the congenital deformity. In rare instances, it is 
true, paralysis may be present at birth, due to intrauterine dis- 
ease or to defect in the nervous apparatus. In such cases the 
cause of the paralysis is usually apparent (spina bifida or spastic 
paralysis associated with defective cerebral development), and 
the treatment does not differ from that of the acquired form. 

Acquired Talipes Equinus. 

In well-marked equinus the foot is plantar flexed to its full 
limit, and it is fixed in this attitude by the shortened structures 
of which the tendo Achillis is the most important. The patient 
walks upon the heads of the metatarsal bones, the toes being 
dorsiflexed to accommodate the deformity. The arch of the foot 
is increased in depth and the tissues of the sole, particularly the 
plantar fascia, are contracted. The foot is broadened and short- 
ened, the breadth being especially increased at the anterior meta- 
tarsal region (Fig. 484). Corresponding to the exaggerated depth 
of the arch, the dorsum projects, the cuneiform bones are promi- 
nent, and the head and body of the displaced astragalus may be 
felt beneath the skin on the anterior surface of the foot. In the 
slighter degrees of the deformity, when the patient still walks 
upon the sole of the foot, the toes are usually dorsiflexed — an 



816 



ORTHOPEDIC SURGERY 



attitude due apparently to the overaction of the extensor longus 
digitorum and proprius hallucis, as aids in dorsiflexion (Fig. 535). 
In rare instances, and only in those cases in which all the 
anterior muscles are paralyzed, the toes may be plantar flexed 
the patient walking upon their dorsal surfaces. 

The cavus or increased depth of the arch is due primarily to 
the flexion of the forefoot at the mediotarsal joint, and in many 
instances this dropping of the forefoot is in great degree respon- 
sible for the equinus ; in fact, the os calcis is rarely plantar flexed 
to the degree commonly found in the ordinary congenital equinus. 




Acquired talipes equinus, showing the limit^ofjiorsal flexion. 

The cases of slight equinus combined with cavus have been 
described already under the title of the contracted foot (page 716). 

Etiology. — Equinus is the most common of the forms of talipes 
acquired in later life. Anterior poliomyelitis, although by far the 
most common cause, is by no means as important in the etiology 
of this as of other varieties of deformity. The nerve supply of the 
anterior muscles of the foot seems to be particularly susceptible, 
and toe-drop, from neuritis of various types, is not uncommon. 

Equinus may be a result of disease of cerebral origin, or even, 
in rare instances, of pseudohypertrophic muscular paralysis, loco- 
motor ataxia, and the like. It is sometimes induced by habitual 
posture, as by long confinement in bed for the treatment of fracture 
or during the treatment of hip disease by apparatus. Or the con- 



DEFORMITIES OF THE FOOT 817 

traction may be an effect of voluntary posture, as when the patient 
habitually walks upon the toes because of a short limb. It is 
a very common sequel of neglected disease at the ankle-joint, 
and it may be a result of direct injury. 

The changes in the internal structure of the foot are similar to 
those that follow other forms of deformity; the tissues on the 
long side are lengthened and attenuated, while those on the short 
side become contracted. The bones themselves are but little 
changed in gross appearance, but the articulating surfaces are in 
abnormal relation to one another; for example, only the posterior 
part of the astragalus may be contained within the malleoli in 
relation to the tibia, while only the lower part of its anterior sur- 
face articulates with the navicular. In all cases of equinus there 
is a strong tendency toward varus or valgus. This is especially 
noticeable in those of paralytic origin. 

Symptoms. — The effects of the deformity vary. If the limb 
is actually shorter than its fellow, so that the lengthening caused 
by the extension of the foot is no more than a sufficient compen- 
sation, and if the foot is firmly fixed in the deformed position, 
there is but little disability and the principal discomfort is from 
corns or calluses beneath the metatarsal bones. 

If the limb is not shorter, the additional length caused by the 
equinus must be compensated by a tilting of the pelvis and lateral 
deviation of the spine. This often causes discomfort in the lumbar 
region. The gait in this class of cases is always awkward, giving 
the impression as of stepping over an obstacle. 

If the foot is not fixed in the attitude of equinus — that is, if it 
hangs downward when it is lifted — the gait is very awkward, 
because of the insecurity and because of the exaggerated flexion 
at the knee necessary to lift the pendent foot. 

If the equinus is extreme the limb is usually flexed at the knee 
when in use. If the equinus is so slight that the foot may be used 
in the plantigrade position, the strain resulting from the limita- 
tion of dorsal flexion is felt at the knee; and in childhood especially 
there is often a well-marked tendency to overextension or recur- 
vation, caused by the effort to place the heel upon the ground. 

In the slight degrees of equinus, discomfort about the calf is 
experienced; the limitation of dorsal flexion causes a short- 
ened stride and awkward gait, while an unguarded step that 
throws a sudden strain upon the rigid heel cord is felt as a shock 
and strain through the leg and body. Very often the patient 
complains of pain about the metatarsal bones (anterior metatar- 

52 



818 ORTHOPEDIC SURGERY 

salgia), and if the equinus is accompanied by a slight degree of 
valgus, as is not uncommon, symptoms of the weak foot may be 
present. 

The prognosis as to permanent cure depends, of course, upon 
the cause of the deformity. When it is simply the result of pos- 
ture or of the ordinary form of neuritis and the like, permanent 
cure may be expected. In many of the cases caused by anterior 
poliomyelitis there has been recovery, complete or partial, of the 
original injury to the spinal centres. But although the power has 
been regained, it cannot be exercised because the foot is held in 
the distorted position by the contracted tissues. In such instances 
practical cure may be predicted if, after the overcorrection of 
deformity, sufficient time is allowed for the overstretched and 
atrophied muscles to regain their proper length and volume. 

Treatment. — In the cases of fixed equinus with a shortened 
limb in which the patient suffers no discomfort a shoe should be 
so built that the entire sole may support the weight. In the more 
extreme cases in which the limb is short and the foot is atrophied 
an extension shoe, attached after the manner of an artificial leg, 
may be worn with comfort and with but little evidence of deformity. 

In the ordinary «cases, whether permanent cure is expected or 
not, the rule holds good that the heel should bear weight, and 
that the range of dorsal flexion should not be limited when the calf 
muscle retains its power. If the paralysis is permanent the foot 
must be supported after the deformity has been corrected; but 
even in this class the gait may be improved and the discomfort 
may be relieved by removing the restrictions to normal motion. 

The slight degrees of equinus in young subjects may be over- 
come by simple manipulation or by retention in a splint or in a 
plaster bandage. If the foot is fixed by a plaster bandage at a 
right angle to the leg it will be found after a few weeks that the 
range of dorsal flexion has been increased by the rest and by 
functional use. Manual stretching of the contracted tissues is also 
of service; for example, the patient being seated extends the limb; 
the surgeon stands in front of him, one hand holds the leg 
firmly at the ankle, and the other grasps the foot, which is 
then dorsiflexed over and over again with as much force as is 
consistent with the comfort to the patient. 

Certain forms of apparatus, for example, the Shaffer extension 
shoe, may be employed with advantage in cases of slight deformity. 

Immediate Correction of Deformity. — Attention has been called 
to the cavus as an important element in equinus, and whenever 



DEFORMITIES OF THE FOOT 



819 



one attempts to correct the equinus deformity the exaggerated 
arch should first be reduced to its normal depth, otherwise the 
foot will appear stunted and deformed. 

One of the most effective procedures is forcible reduction by 
means of the Thomas wrench (Fig. 518). ^ The resistant bands 
of the plantar fascia are first divided subcutaneously, the wrench 
is then fixed to the foot, and by sudden force exerted against 
the resistant tendo Achillis the foot is ■ straightened, 'the con- 
tracted tissues being ruptured or stretched to the proper degree. 




A brace with a "limited" joint, allowing 
slight motion at the ankle. 



A brace to prevent foot-drop. One 
upright is often sufficient. 



The resistance to normal dorsal flexion is then overcome by 
manual force, or, if this is ineffective, by subcutaneous division 
of the tendo Achillis, and the foot is fixed by a plaster-of-Paris 
bandage in an attitude of dorsiflexion. 

As the patient is encouraged to walk upon the foot as soon as 
possible, the weight of the body forcing the relaxed tissues against 
the plaster sole, reinforced, if necessary, by a wooden foot-plate 
completes the flattening of the arch. In many of these cases the 
knee has been overextended by use in the deformed attitude, so 
that the habitual flexion necessary to bring the dorsiflexed foot 



820 ORTHOPEDIC SURGERY. 

upon the ground during the two months allowed for the complete 
union of the divided tendon is of benefit, as it serves to correct 
this secondary weakness and deformity. 

The Tonic Effect of Immediate Correction. — The im- 
portance of the tonic effect of immediate relief of the strain of 
the deformed position upon the weak anterior group of muscles, 
together with the complete relaxation of the overstretched tissues, 
during the long rest in the overcorrected position is not generally 
appreciated. Whenever the weakened muscles after paralysis 
show by tests, electrical or otherwise, that they have recovered 
their power in part, overcorrection of the deformity should be 
the treatment of selection. The application of electricity or other 
form of stimulation to muscles that are unable to exercise their 
function because of contraction of the opposing tissues is practically 
useless; nor is any other form of artificial stimulation equal to 
that of the functional use, which is made possible by the removal 
of the deformity and by the employment of proper support. 
Equinus, more often than any other deformity, is the result of 
slight or temporary disability of the anterior group of muscles, 
and not infrequently perfect cure seems to have been attained 
when the plaster bandage is finally removed, usually at the end of 
two months or more; but even in such cases the application of 
a simple support to hold the foot at a right angle with the leg for 
several months is of advantage. The after-treatment by massage, 
muscle-beating, electricity, and the like, combined with method- 
ical passive movements to the limit of dorsal flexion to guard 
against recontraction of the calf muscle, should be continued for 
a long time or until the muscular balance has been regained. 

Support is, of course, necessary, in cases of hopeless paralysis, 
to hold the foot at a right angle with the leg. The common form 
is a simple steel sole-plate of sufficient size to support the sole, 
and the toes, also, if their muscles are paralyzed, attached to a 
light upright, provided with a calf band. The upright is usually 
applied on the inner side of the leg, where it is least noticeable. 
At the ankle there is a "stop joint," which allows dorsiflexion 
but prevents the toe-drop. This, when properly fitted, can be 
placed inside the ordinary shoe, as the paralyzed foot is usually i 
somewhat smaller than its fellow (Fig. 537). If the toes do not 
need support, the upright can be attached to the outside of the 
shoe and the foot-plate may be dispensed with; or, the upright 
may be concealed by introducing it inside the shoe to a joint sunk 
in the heel, the toe-drop being prevented by straps passing from 



DEFORMITIES OF THE FOOT 



821 



the front of the upper leather of the shoe to the calf band (Fig 
538). 

Arthrodesis. — In this class of cases in which the anterior muscles 
are paralyzed the operation of arthrodesis for the purpose of 
fixing the foot at a right angle with the leg is of value. In most 
instances the mediotarsal as well as the ankle-joint must be 
operated on. Under the Esmarch bandage the two joints 
are opened by an incision in the centre of the foot, beginning 





An effective and inconspicuous support for paralytic toe-drop. An upright of light tem- 
pered steel, carefully adjusted to the inner side of the leg and ankle, provided with a light 
calf band. This is strengthened by a posterior support attached to the upright. The lower 
end of the brace is arranged as a caliper and is fitted to the metal disk, of which two views 
are shown. A depression is cut in the heel of the shoe for the disk, as is shown in the dia- 
gram. Two strong elastic tapes are sewed to the leather of the shoe. These are attached 
to the studs on the front of the calf band, and thus the toe-drop is prevented. (See Fig. 539.) 



about one inch above the ankle-joint and extending downward 
for about three inches. The cartilaginous surfaces of the astrag- 
alus and leg bones may be removed easily with a narrow-bladed 
knife or thin, sharp chisel, while the foot is held in plantar flexion. 
At the mediotarsal joint a thin, wedge-shaped section, base up- 
ward, including the astragalonavicular and calcaneocuboid joints, 
may be removed also in order to prevent the subsequent sinking 
of the forefoot. 



822 



ORTHOPEDIC SURGERY 



If there is restriction of dorsal flexion the foot should be forced 
up to a right angle with the leg against the resistance of the tendo 

Achillis, thus pressing the 
denuded surfaces together. 
In other instances silk sutures 
may be passed through the 
periosteum of the opposing 
bones. The wound is then 
closed with catgut ligatures 
and a plaster-of-Paris band- 
age is applied to hold the 
foot at a right angle with 
the leg. Operations of this 
character on the bones are 
sometimes followed by swell- 
ing. On this account the 
bandage should be applied 
over a thick layer of elastic 
cotton and the foot should 
be elevated. As soon as the 
discomfort has subsided the 
patient should use the foot in 
walking. No support is equal 
in efficiency to the plaster 
bandage. This should be 
worn for several months, 
when it may be replaced by 
a light supporting brace of 
the Judson type (Fig. 541). Equinus due to posture or to disease, 
not involving paralysis, may be cured by simple correction of the 
deformity. Resistant deformity following fractures at the ankle 
may be overcome satisfactorily by astragalectomy. 




The same appliance (Fig. 491) provided with a 
foot plate of metal or of wood as shown in the 
diagram. This modification is useful if the par- 
alysis is complete or if the foot is much atrophied. 



Acquired Talipes Calcaneus. 

Acquired talipes calcaneus is much less common than equinus, 
and it is practically always of paralytic origin (anterior polio- 
myelitis), although cases of calcaneus following injury or disease 
or distortion of the limb are occasionally seen. 

There are several varieties or grades of the deformity. In the 
early stage, and especially if all the muscles of the posterior group 
have been paralyzed, the foot assumes an attitude of slight dorsi- 



DEFORMITIES OF THE FOOT 823 

flexion, and the range of plantar flexion is gradually lessened by 
secondary contractions. This variety resembles closely the con- 
genital form (simple calcaneus) (Fig. 485). In the ordinary and 
typical form of calcaneus, when fully developed, the patient 
walks, as the name implies, on an elongated heel. The arch of 
the foot is much increased in depth, and the forefoot is atrophied 
and useless (calcaneocavus) (Fig. 542). 

Development of Deformity.— The development of the deformity 
is somewhat as follows: When the tension of the calf muscle is 
removed the os calcis gradually assumes an attitude of extreme 
dorsiflexion. It stands on end, so that its posterior surface 
becomes inferior. The projection of the heel is lessened and 
often it lies in the plane of the atrophied calf. The change in the 
position of the os calcis increases the distance from the malleoli 
to the ground; thus calcaneus, though in less degree than equinus, 
makes the limb longer. The turning of the heel on end increases 
the depth of the longitudinal arch and at the same time shortens 
the foot, thus cavus is a later complication of nearly all 
cases of paralytic calcaneus. In many instances there is no per- 
manent dorsiflexion or elevation of the forefoot, although in 
all cases the range of plantar flexion is limited. In this class the 
power in the remaining muscles of the posterior group is probably 
sufficient to counterbalance the action of the dorsiflexors. Cavus 
is thus a direct effect of the displacement of the os calcis. If 
the entire posterior group of muscles is paralyzed, while the 
anterior muscles are unaffected, the foot will be somewhat dorsi- 
flexed and the cavus will be less marked. If the calf muscle only 
(gastrocnemius and soleus) is paralyzed, the remaining muscles 
of the posterior group will counterbalance the dorsiflexors and at 
the same time increase the cavus. In some instances the calf 
muscle alone is affected; in others one or more of the smaller 
muscles may be paralyzed also, in which case the foot is usually 
turned toward varus or valgus. The changes primarily caused 
by the paralysis and by unopposed muscular action become fixed 
by habitual use and by secondary adaptation of the tissues. The 
heel only is used in walking, and the area of callus which marks 
its weight-bearing surface becomes much enlarged, while the 
forefoot and toes become a mere appendage to the enlarged heel, 
a striking illustration of the atrophy that follows disuse (Fig. 542). 

Symptoms. — The gait is shambling, the patient, who is, as it 
were, "hamstrung," stamps along upon the insecure heel in a 
manner which is easily recognizable by one familiar with the 



824 



ORTHOPEDIC SURGERY 



deformity. The changes in the internal structure of the foot, the 
inevitable adaptations to the deformity, do not call- for special 
description. The disused bones atrophy together with the other 
tissues, and new articulating surfaces form to accommodate the 
necessities of functional use. 

Treatment. — When the diagnosis of paralysis of the calf muscle 
is made one may predict, unless recovery takes place, a deformity 
such as has been described. This deformity may be prevented by 
proper support, by massage and methodical stretching of the tissues 
that have a tendency to contract. The form of brace used for 
walking and support should be provided with a sole plate, upright, 
and calf band, as already described in the treatment of paralytic 





Judson's brace for calcaneus deformity. 



equinus. If motion is allowed at the ankle it should be in plantar 
flexion only, the stop being the reverse of that used in equinus; 
or, as this form of check entails much strain upon the brace, the 
joint may be omitted, as in that form used by Judson (Figs. 540 
and 541). Thus the strain, removed from the weakened tissues, 
is borne by the anterior surface of the leg. Other forms of 
braces are sometimes employed, prodded with elastic bands to 
supply the place of the calf muscle; but, as a rule, the improve- 
ment in gait hardly compensates for the trouble in adjustment or 
the conspicuousness of the appliance. 

The most important part of the actual deformity of calcaneus 
is the cavus, and in confirmed cases it is practically impos- 



DEFORMITIES OF THE FOOT 



825 



sible to reduce this directly, because the loss of resistance of the 
tendo Achillis takes away the point of fixation against which 
effective force can be exerted. If the deformity is not marked 
the foot may be drawn as far as possible toward equinus and 
fixed in a plaster bandage, the sole part being strengthened by 
the insertion of a thin board. Upon this the patient may walk, 
the heel being built up with cork wedges to make the sole level. 
When the contraction of the anterior tissues has been overcome 




Paralytic calcaneus, showing secondary changes in contour. 

the brace is applied and the usual treatment of manipulation and 
massage is continued. 

The method of prolonged fixation in the attitude of equinus by 
means of the plaster bandage is often of value in childhood, 
when the paralysis is not complete, and cures of apparently hope- 
less cases by this means have been reported. 1 

Operative Treatment. — In more extreme cases immediate reduc- 
tion of the deformity under anaesthesia may be attempted. The 
contracted tissues, more particularly the plantar fascia, may be 

1 Gibney, Transactions of the American Orthopedic Association, 1900, vol. xiii. 



826 



OB THOPEDIO SUBGEBY 



divided subcutaneously or by open incision; then by forcible 
manipulation or wrenching the sole may be somewhat lengthened 
and the heel pushed upward and backward to permit of slight 
plantar flexion. In this attitude the foot should be fixed by 
means of a plaster bandage. In the reduction of the deformity 
one must not merely force the forefoot downward, as this would 
simply increase the cavus, but whatever correction is accomplished 
should be by means of elevation of the os calcis and elongation 




Talipes calcaneus clue to paralysis of the calf muscle (gastrocnemius and soleus), 
illustrating the typical deformity of moderate degree. 

of the tissues of the sole of the foot. In cases of extreme de- 
formity the contracted tissues in the anterior aspect of the ankle 
must be divided also. 

In some instances the improved position of the os calcis may 
be assured by shortening the tendo Achillis, as first performed 
by Willett, of London. 1 

Willett's Operation for Calcaneus. — A Y-shaped incision about 
two inches in length is made through the tissues down to the 
tendon. At the lower or vertical part of the incision, which is 
continued down to the tuberosity of the os calcis, the tendon is 

" St. Bartholomew's Hospital Reports, 1SS0, vol. xvi, p. 309. 



DEFORMITIES OF THE FOOT 



827 



dissected free from the surrounding parts. It is then divided in 
an oblique direction from within outward and downward, and the 




Talipes calcaneovalgus. In this form the adductors of the foot (tibialis anticus and 
posticus) as well as the calf muscle are paralyzed. 

heel having been pushed upward as far as possible the divided ends 
are overlapped and sutured; the flap of skin is drawn downward 




Illustrating the effect of the operation in restoring symmetry. 
Compare with Fig. 543. Compare with Fig. 544. 

at the same time, so that the Y-incision is converted into the 
shape of a V. According to Mr. Willett's original directions, 
deep sutures are passed through the skin flaps and through the 



828 ORTHOPEDIC SURGERY 

tendon on either side, so that all the tissues are united. The 
foot is then fixed in a plaster bandage in an attitude of equinus. 
As soon as practicable the patient begins to use the foot, wearing 
a high heel to compensate for the elevation of the sole. 

Palliative operations of this class are of value in those cases in 
which some power remains in the calf muscle, which is thus 
made serviceable. In cases of complete paralysis the shortened 
tendon offers some resistance to deformity, but unless proper 
support is used afterward the tissues will stretch under the strain 
of use; thus the treatment should always be supplemented by a 
brace of the character already described (Fig. 541). 

Fig. 547 



Figs. 544, 545, and 546 illustrate the effect of treatment by removal of the astragalus and 
backward displacement of the foot in cases of paralytic talipes calcaneovalgus. In the 
later operations the backward displacement has been increased as described in the text. 

Astragalectomy, Arthrodesis, Tendon Transplantation, and Backward 
Displacement of the Foot (the Author's Operation 1 ). — More effective 
treatment is indicated in cases of confirmed calcaneus and especially 
calcaneus combined with lateral deformity which makes the adjust- 
ment of a brace difficult. 

A long, curved, external incision is made, passing from a point 
behind and above the external malleolus below its extremity and 
terminating at the outer aspect of the head of the astragalus. 
The peronei tendons are divided as far forward as possible and 
they are then completely separated from their sheaths and drawn 
to one side. The joint is then opened and the foot is displaced 

1 American Journal of the Medical Sciences, November, 1901. 



DEFORMITIES OF THE FOOT 829 

inward. This forces the astragalus out from between the malleoli 
and it is easily enucleated when its attachments to the neighboring 
bones have been divided. A thin section of bone is then cut from 
the outer surface of the os calcis and cuboid bones. On the inner 
side the sustentaculum tali is cut away and the calcaneonavicular 
ligament is partially separated from its attachments. The carti- 
lage is then removed from the two malleoli and if necessary they 
are reshaped to permit accurate adjustment. The foot is then 
displaced backward as far as possible so that the external malleolus 
may cover the calcaneocuboid junction while the inner is forced 



An effective brace for talipes calcaneus, consisting of two light lateral steel bars joined 
above by a padded band of steel, which crosses the upper third of the tibia, and below by a 
narrow sole plate. A leather heel support also adds somewhat to the efficiency of the appa- 
ratus. In most instances the heel should be somewhat elevated by a cork wedge placed 
within the shoe. 

into the depression behind the navicular. Finally, the peronei 
tendons, if the muscles are active, are attached to the insertion of 
the tendo Achillis and to the os calcis by strong silk sutures. The 
wound is closed without drainage, and the foot is then fixed by a 
plaster bandage in an attitude of equinus. The object of the 
removal of the astragalus is to assure stability and to prevent 
lateral deformity by placing the leg bones directly upon the 
foot. The object of the backward displacement of the foot 
is to direct the weight upon its centre and thus to remove the 
adverse leverage that induces dorsal flexion. The tendon trans- 
plantation is an additional safeguard against deformity and of 
some service in restoring function. , 



830 OB THOPEDIC S UR QER Y 

As soon as possible the patient uses the foot in standing and 
walking. Ultimately apparatus may be dispensed with, but the 
Judson brace or the appliance shown in Fig. 548 should be used 
for a year or more with advantage, when it may be replaced by 
a shoe arranged to hold the foot in slight equinus. This operation 
has been performed in upwards of fifty cases by the author, for 
whom it is now the treatment of choice in this type of deformity. 

Acquired Calcaneovalgus and Calcaneo varus. 

In many cases, the foot deformed as a result of paralysis of 
the calf muscle is in addition turned in a lateral direction, so 
that the weight of the body falls to the inner or outer side of its 
centre (Fig. 544). 

Calcaneovalgus, in which the foot is turned outward and 
upward, so that the patient walks on the inner side of the heel or 
even on the inner ankle, is not uncommon. It is usually a result 
of more extensive paralysis than simple calcaneus. For example, 
all the muscles about the foot may be disabled except the peronei, 
or in cases of a milder type the tibialis anticus may be the only 
muscle of the front of the foot that is paralyzed. 

Treatment. — When the foot inclines toward calcaneovalgus it 
is difficult to hold it in proper position. The usual method is to 
apply the brace, used for ordinary calcaneus, with the upright on 
the outer side of the foot; the ankle and arch are then held against 
it by means of a leather strap. Another form of brace is provided 
with an upright on either side of the leg, the outer being slightly 
longer than the inner, so that the sole plate is tilted inward or, 
as it were, supinated; thus the weight is guided toward and bal- 
anced on the outer side of the foot. In many instances of this 
character other muscles of the limb are paralyzed, the deformity 
of the foot being but a part of more general distortion. In such 
cases the foot brace must be combined with apparatus for the 
support of the leg (Fig. 394). 

Calcaneovarus is a much less serious affection, since the foot 
may be more easily supported. A brace, such as is used in the 
treatment of ordinaiy varus, without motion at the ankle or 
provided with a reverse stop, is ordinarily employed. Operative 
treatment is especially indicated for confirmed deformity of the 
valgus or varus type after the method last described. 



DEFORMITIES OF THE FOOT 831 



Acquired Talipes Equinovarus. 

Talipes equinovarus is, in the acquired as in the congenital 
form, the most common of the deformities of the foot (Fig. 552). 

The tendency of simple equinus is usually toward varus, because 
in plantar flexion the foot is slightly adducted and because the 
outer side of the foot is shorter than the inner side, so that in 
walking with the foot extended the tendency of the foot is to 
turn somewhat inward. Equinovarus is usually preceded by 
equinus, and the etiology of the one will serve for the other (page 
815). 

In certain cases the varus is more marked than the equinus, 
as, for example, when the abductors of the foot are paralyzed 
while the adductors retain their power; or in cases of direct injury, 
as in fracture at the ankle; or when the growth of the tibia has 
been arrested, as the result of injury or disease. 

A detailed account of the appearance and effect of the deformity 
is unnecessary. 

If the deformity is resistant it should be reduced and overcor- 
rected by forcible manipulation under anaesthesia. Division of re- 
sistant parts is less often necessary than in the congenital form, but 
it may be required in neglected cases. The overcorrected position 
should be retained until time has been allowed for the recontrac- 
tion of the lengthened tissues; for, as has been mentioned in the 
treatment of equinus, overcorrection and rest is by far the most 
effective treatment that can be applied to a weak or paralyzed 
part. The foot must then be supported by a brace, of which the 
Taylor club-foot apparatus is the type (Fig. 505). 

Astragalectomy and cuneiform osteotomy are rarely indicated, 
but the latter operation is sometimes of service in checking the 
tendency toward recurrence of deformity, which is more persistent 
after overcorrection in the paralytic than in the congenital talipes. 

Transplantation of half of the tendon of the tibialis anticus 
tendon to the periosteum or bone of the outer border of the foot, 
combined with arthrodesis of the astragalus navicular articulation 
in an attitude of slight abduction, is of service as a curative pro- 
cedure. (See Tendon Transplantation.) 

Acquired Talipes Equinovalgus is much less frequent than the 
preceding deformity. Simple equinovalgus is usually the result 
of primary paralysis of the tibialis anticus, the most powerful of 
the dorsal flexors; thus the foot is drawn somewhat outward 



832 ORTHOPEDIC SURGERY 

when dorsiflexed, while the metatarsal bone of the great toe, 
having lost the proper support of the paralyzed muscle, falls down- 
ward and is drawn outward by the peroneus longus. In this 
type one's attention is often attracted by the peculiar appearance 
of the great toe, which is deformed somewhat like a hammer-toe 
by the overaction of the extensor longus hallucis in its attempt 
to take the place of the tibialis anticus. The equinus is usually 
slight and is secondary to the valgus. Treatment may be begun 
by placing the foot in a plaster bandage in an attitude of varus 
and allowing the patient to walk upon it until the tendency 
toward deformity has been overcome. A support with the catch, 
as for toe-drop, is applied to the shoe, and the tendency toward 
valgus is checked by raising the inner border of the sole or by the 
use of a sole plate, as in the treatment of the simple weak foot 
(Fig. 455). In this class of cases tendon transplantation, partic- 
ularly the implantation of the tendon of the extensor longus 
hallucis in the region of the navicular, combined with arthrodesis 
of the astragalonavicular articulation to fix the foot in the 
attitude of adduction is particularly effective. 

Acquired Simple Talipes Valgus from combined paralysis of 
the tibialis anticus and posticus is rare. Talipes valgus, as when 
the foot is dislocated outward, in cases of complete paralysis of 
all its muscles, may be considered as a variety of dangle-foot. 

Traumatic valgus and equino valgus caused by fracture at the 
ankle (Pott's fracture) may be treated by osteotomy of the tibia 
above the ankle. By this means the proper relation of the leg 
to the foot may be restored in many instances. Equinovalgus 
of slight degree is not uncommon after tuberculosis or rheumatoid 
disease at the ankle or at the astragalonavicular joints. This is 
practically one variety of weak foot. 

Talipes valgus, sometimes called spurious valgus, the simple 
weak or flat-foot, has been described elsewhere. (Chapter XX.) 

Talipes caused by cerebral disease, whether of the paraplegic 
or the hemiplegic type, is in early childhood almost always of 
the form of equinovarus. In adolescence the deformity may be 
equinovalgus or even calcaneovalgus if there is extreme flexion at 
the knee. The hemiplegic form of talipes is much more rigid 
and unyielding than the paraplegic type. The treatment of 
spastic paralysis, of which the deformity is a part, is discussed 
elsewhere. (Chapter XVIII.) The deformity must be corrected 
by the ordinary methods. In many instances when the contrac- 
tions are not marked mechanical treatment is unnecessary. 



DEFORMITIES OF THE FOOT 833 

Hysterical equinovarus or other form of deformity is not espe- 
cially rare. The diagnosis may be made from the other symptoms 
of hysteria, from the history of the onset and duration of the 
distortion, and from the appearance of the deformity, which is 
evidently merely an assumed posture. (See page 638.) 

Tendon Transplantation for the Relief of Paralytic Talipes. 

When one or more of the muscles are paralyzed the unbalanced 
action of those that remain tends to distort the foot. The object 
of the brace in such cases is to hold the foot so that the muscular 
traction, however applied, can move it only in the proper direc- 
tions. The object of tendon or muscle transplantation is to utilize 
the muscular power that remains to the best advantage. Thus a 
muscle which only serves to distort the foot may be transplanted 
to a point where it may restrain deformity and improve functional 
ability. 

Tendon transplantation was first performed by Nicoladoni in 
1882 1 for the relief of paralytic calcaneus. The tendons of the 
peroneus longus and brevis were divided behind the external 
malleolus, and the proximal ends united to the distal extremity 
of the divided tendo Achillis. 

The first operation on the front of the foot was performed 
by Parish, 2 of New York, for the relief of paralytic valgus, by 
sewing the tendon of the extensor proprius hallucis to that of the 
paralyzed tibialis anticus, without division of either tendon. In 
more recent years the field of the operation has been extended by 
Drobnik, 3 Goldthwait, 4 Lange, and many others, to include almost 
every possible combination of tendons and muscles. 5 

The functions of the muscles and their relative order of impor- 
tance in the execution of each movement are indicated in the 
following table, modified somewhat from that of Codivilla: 

1 Archiv f. klin. Chir., 1882, iii., xxvii., S. 660. 

2 New York Medical Journal, October 8, 1892. 

3 Cent. f. Chir., July, 1894, N. 7. 

4 Transactions of the American Orthopedic Association, 1896, vol. viii. 

6 For a complete bibliography up to 1902, see Vulpius, Die Sehnenuberpfianzung, etc., 
Leipzig, 1902. 



53 



834 



ORTHOPEDIC SURGERY 



Dorsal Plantar Adduc- Abdue- Prona- Supina- 
flexion. flexion tion. tion. tion. tlon. 



Tibialis anticus .... 


. ; i 










1 


Extensor proprius hallucis. . 
" longus digitorum 1 . 


. • 3 




... 






6 


2 






3 


3 




Peroneus brevis .... 




6 




2 


2 




longus .... 




3 




1 


1 




Gastrocnemius and soleus 




1 


2 






2 


Tibialis posticus 




4 


\ 






3 


Flexor longus hallucis 




2 


3 






4 


" " digitorum . 


■ ! - 


5 


4 






5 



Time for Operation. — The operation should not be undertaken 
until the degree of final and irremediable paralysis has been 
determined. This stationary stage may be reached in a com- 
paratively short time, but in the ordinary cases in which, for 
want of protection, the part has become distorted, it is practically 
impossible to estimate the latent muscular power until the defor- 
mity has been corrected, and until the enfeebled muscles have 
been stimulated by functional use. In general, a period of two 
years at least should intervene between the onset of the paralysis 
and the operation. 

The first essential for success by this means is a clear under- 
standing of the mechanism of the disabled part and of the relative 
importance of its functions. As regards the foot, for example, 
plantar flexion is far more important than dorsal flexion, because 
the inability to plantar flex implies the loss of the principal lifting 
and propelling power of the body. Dorsal flexion is more im- 
portant than adduction or abduction, because the drop-foot, 
so-called, interferes seriously with locomotion. Adduction is 
more important than abduction, because the loss of power to 
turn the foot inward induces the attitude of valgus, which is more 
disabling and more difficult to remedy than the opposite deformity. 
To the importance of these movements the power of the muscles 
corresponds. 2 

Selection of Muscles. — In selecting muscles for transplantation 
one attempts usually to reduce the distorting power as well as 
to replace lost function. For example, if the tibialis anticus 
were paralyzed one would naturally replace it by its adjunct, 
the extensor hallucis, and as the power of raising the toe is not 
essential it should be separated and transferred entire to its new 
position. This might complete the operation, or the principal 
abductor on the dorsal surface of the foot might be divided and 



Including peroneus tertius. 
See Tables on page 676. 



GASTROCNEMIUS 



m 



1 



i. 3 «f 






The muscles and tendons on the front of the The muscles and tendons on the back of the 
leg (Testut, from Gerrish's Anatomy.) leg. (Testut, from Gernsh's Anatomy.) 



836 



OR THOPEDIC SURGERY 



the proximal end attached to the periosteum or bone near the centre 
of the foot to further assure the success of the operation. 

If, on the other hand, the dorsal abductors were reduced in 
strength so that the foot turned inward in dorsiflexion, the tibia- 
lis anticus tendon should be split, from its insertion to the mus- 
cular substance, and the outer half 
carried over the other tendons and 
fastened securely at or near the in- 
sertion of the peroneus tertius as well 
as to that tendon; thus the power of 
supination would be weakened and 
that of pronation increased. 

If the calf muscle is paralyzed, and 
if the foot is inclined toward valgus 
because of weakness of the adductor 
group, the two peronei tendons may 
be attached at the insertion of the tendo 
Achillis, not, of course, with the aim of 
replacing its lost function by two such 
feeble muscles, but because they might 
aid in preventing deformity and be- 
come of some functional service, even 
if slight. 

Paralysis of the tibialis posticus 
muscle may be treated by dividing the 
peroneus brevis at or near its inser- 
tion, passing it beneath the tendo 
Achillis and attaching it to the tendon 
of the former. It may be mentioned, 
also, that portions of the tendo Achillis 
have been used to strengthen either the 
posterior adductors and abductors. As 
has been stated, one must plan the oper- 
ation according to the function that is 
lost and the power that remains. As 
a rule, the most successful operations 
are those in which a muscle of similar function to that of the 
paralyzed one is transplanted. It is apparent, also, that it will be of 
little use to transpose a muscle unless its origin is such that it can 
work to advantage at its new point of attachment. For example, 
an anterior adductor may be changed to an abductor, and a 
posterior adductor or abductor can be similarly transferred, but a 




Tendons in the right sole. (Testut 
from Gerrish's Anatomy.') 



DEFORMITIES OF THE FOOT 



837 



posterior abductor is unlikely to be efficient as a dorsal flexor; 
nor can one muscle act as an extensor and as a flexor at the same 
time, as would appear to be the belief of those who attach a portion 
of the tendo Achillis to the tibialis anticus tendon with the aim 
of restoring the power of dorsal flexion. The variety of com- 
binations of this character that have been advocated is very large, 
but it is hardly necessary to describe them. As has been men- 
tioned, one may always sacrifice a less important to a more im- 
portant function, and as a weak muscle can hardly carry out its 




Paralytic equinovarus before operation. (See Fig. 553.) 

original function and a more important one as well it is advisable 
in most instances to relieve it completely of the first in making 
the transfer. 

The Operation. — The technique of the operation is simple. All 
restriction to normal motion must be overcome by manual force, 
and, if necessary, by tenotomy as a preliminary measure. The 
operation should be performed under an Esmarch bandage. 
The incision either continuous or divided should expose the mus- 
cular substance of the muscles and the point at which the trans- 
planted tendon is to be attached. By exposing the parts one is 



838 



ORTHOPEDIC SURGERY 



able to verify the previous diagnosis. A completely paralyzed 
muscle is atrophied and of a dull, reddish-yellow color, and its 
tendon is of a yellowish-white tinge. A partially paralyzed muscle 
is atrophied, its tendon is small, but it retains the silvery glisten 
of the normal structure. The tendon sheaths having been opened, 
the tendon is divided or split near its insertion, and having been 
freed from any restraint that might impair its power it is placed 
in apposition to the tendon of the paralyzed muscle, whose surface 
has been freshened with the knife. The two are then attached to 
one another by several sutures of fine silk, and the graft is covered 




Paralytic equinovarus cured by operation, showing power of dorsal flexion (one-half of 
the'tendon of the tibialis anticus attached to the periosteum of the outer border of the foot) . 
Operation July 19, 1898. The direct union of tendons to periosteum at the most advantage- 
ous point has been urged especially by Lange (Ueber Periostale Schnenverplanzung bei 
Lahgmung, Munch. med.Woch., 1900, No. 15). 

by uniting the tendon sheath or fatty tissue over it with fine cat- 
gut. The skin incision is closed with a continuous catgut suture. 
It should be stated that the graft is applied under a certain tension, 
all the slack being drawn in, as it were, so that the foot is held if 
possible in the normal attitude. This is further assured in most 
instances by shortening the tendon of the paralyzed muscle. A 
plaster bandage is then applied in the overcorrected position, 
and in this attitude the foot should be used for many months. 

Modifications of the Operation. — Since its introduction the opera- 
tion of tendon transplantation has been modified in several par- 
liculars. It has been demonstrated by experience that there is 



DEFORMITIES OF THE FOOT 



839 



a strong tendency toward relapse to the original condition, either 
because of weakness of the transposed muscle or because of 
displacement of the new attachment. This indicates the neces- 
sity of long continued fixation in the overcorrected attitude and 
of subsequent support by braces until one is certain of the final 
outcome. 

It has been urged by Lange that the tendon of the living muscle 
should not be attached to that of the paralyzed one, but should 
be fixed directly to the periosteum at the point of greatest mechan- 




Talipes equinovalgus after treatment by tendon transplantation. The tendon of the 
peroneus tertius was attached to the overlapped and shortened tendon of the tibialis anticus. 
A.11 the tendons on the front of the foot were then united, so that all might serve as dorsal 
flexors. 



ical efficiency. If the tendon is not long enough for this 
purpose it may be lengthened by means of a silk cord incorpor- 
ated in its substance, about which it is assumed, new tendinous 
material will form during its absorption. Wolff has suggested 
implanting the end of the tendon berieath the cortex of the bone, 
and I have gone still farther in the interest of security by boring 
a hole completely through the bone to which the attachment is to 
be made, passing the tendon through it and sewing it to itself 
and to the periosteum on the other side. Thus, in utilizing the 
extensor longus hallucis to replace the tibialis anticus the hole is 



840 ORTHOPEDIC S UEGER Y 

made in the navicular. The tendon, having been divided about 
one inch from its insertion, is passed through and drawn tight 
enough to hold the inner border of the foot at a right angle to 
the leg. The tendon of the paralyzed tibialis anticus is then cut, 
overlapped, and sutured to aid in relieving the strain. If the 
tibialis anticus muscle, on the other hand, is to be used as an 
abductor it is split in the manner described, and as it is not long 
enough for bone implantation a cord of silk is quilted into it and 
passed through the cuboid, while the tendon itself is attached to 
that of the peroneus tertius and to the periosteum in the usual 
manner. Silk may be depended upon to hold for several months, 
although it is not completely absorbed for several years. For 
uniting adjacent tendons the continuous suture over a wide extent 
of surface is most secure. 

Tendon Transplantation in Combination with Other Procedures. — 
As the object of operative treatment is to prevent deformity and 
to increase the stability of the foot, tendon transplantation may 
be of greater service when combined with other operations. One 
of these has been mentioned in the treatment of talipes cal- 
caneus. (See page 828.) For valgus deformity arthrodesis of the 
astragalonavicular articulation is a valuable adjunct of tendon 
transplantation. An incision about three inches in length, long 
enough to expose the muscular substance of the extensor longus 
hallucis and the astragalonavicular articulation is made. This 
joint is then opened and the cartilage is thoroughly removed from 
the adjoining bones. A hole is then bored through the navicular 
through which the hallucis tendon is passed. This is drawn 
taut and sewed to the bone and to itself. The foot is forced 
into an attitude of adduction and the denuded bones are sewed 
firmly to one another with strong silk. A similar procedure is 
employed if the deformity is of the varus type. A thin wedge of 
bone, including the calcaneocuboid and the outer half of the 
astragalonavicular articulation, is removed from the dorsal aspect 
of the foot. Forced abduction closes the opening and continued 
contact is assured by several heavy silk sutures. 

The foot should be retained for several months in the over- 
corrected position by a plaster bandage, on which the patient 
walks about until the parts have become adapted to the new posi- 
tion. In many instances further support is unnecessary, but a 
brace should be used if there is a tendency toward deformity. 

The prognosis depends upon the degree of permanent paralysis 
and its distribution. It is, of course, evident that tendon trans- 



DEFORMITIES OF THE FOOT 841 

plantation is essentially a palliative rather than a curative oper- 
ation. In selected cases in which the attachment is directly 
to the bone, and especially when lateral motion is checked by 
arthrodesis, the results are very satisfactory. The improvement in 
functional ability is immediately shown in the improved circula- 
tion and size of the limb. In some cases of this class the trans- 
ferred muscle apparently undergoes an adaptive hypertrophy. 
It is needless to say that such results are favored by massage 
and by appropriate exercises. Even in those cases in which 
the result is far from satisfactory, some improvement is usually 
apparent. 

The principles of tendon transplantation may be applied in 
other situations. For example, the trapezius may replace the 
deltoid (page 618), the sartorius or the tensor vaginae femoris 
muscle may be attached to the tendon of a paralyzed quadriceps 
extensor muscle for the purpose of restoring in some degree the 
ability to extend the leg (page 619). 

The flexor muscles may be transplanted to the extensor aspect 
of the thigh to overcome persistent contracture, the result of 
spastic paralysis (page 632). 

The operations for the relief of hemiplegic deformity of the 
hand have been mentioned (page 630). 

Tendon Splicing. — Division and overlapping of the tendons of 
paralyzed muscles may be employed with advantage in certain 
instances. For example, in complete paralysis of all the dorsal 
flexors of the foot, each tendon may be shortened and attached 
to the anterior ligament; thus the toe-drop may be remedied or 
reduced to such an extent that the deformity may interfere but 
slightly with locomotion. As a rule, however, apparatus must 
be employed to prevent a recurrence of the deformity unless it be 
combined with arthrodesis. 

Arthrodesis. 

The removal of the cartilaginous surfaces of articulating bones 
and thus inducing anchylosis for the relief of paralytic deformi- 
ties of the foot, was first performed by Albert, of Vienna, in 1878. 
As applied to the foot, it is of special service in those cases in which 
practically no muscular power remains, the so-called dangle-foot. 
It may be of service, also, in cases of less disability, as in equinus 
or calcaneus, when the patient is unable to provide himself with 
apparatus or desires to dispense with it. 



842 OB THOPEDIC S UR GEB Y 

The operation consists in opening the joint and removing the 
cartilage from the apposed surfaces of the bones, then sewing 
them to one another, or simply fixing the parts in a plaster bandage 
until union has taken place. If the case is one of simple calcaneus 
or equinus, without lateral deviation, the operation may be limited 
to the ankle-joint, which may be opened from the back or front 
side, as seems preferable. As has been stated, the usual incision 
is about two inches in length over the front of the ankle-joint. 
The foot is then plantar flexed and the cartilage is thoroughly 
removed from the articulating surfaces with a thin chisel or knife. 
The lateral incision as used for the removal of the astragalus allows 
a more thorough inspection of the joint and in many instances it is 
to be preferred. The wound is then closed, and the denuded bones 
are forced into accurate apposition and fixed by a plaster bandage. 
As soon as possible the patient is encouraged to use the foot. As 
a rule, in cases of complete paralysis of the anterior group simple 
anchylosis at the ankle-joint is not sufficient to prevent the toe- 
drop, and it is well to destroy the mediotarsal joint also. A 
convenient method is to remove the cartilaginous surface of 
the astragalonavicular and calcaneocuboid articulations, together 
with a thin wedge of bone, base uppermost. In some instances 
the tendons of the paralyzed muscles are shortened to aid in re- 
taining the foot in the improved position. This, however, is of 
minor importance. The operation should be performed under 
the Esmarch bandage, and the limb should be elevated for a time 
to prevent the subsequent bleeding from the bones. 

The improvement in the gait, obtained by the rectification of 
deformity, and by fixation of the foot, after arthrodesis, is often 
very marked, and in many instances support may be discarded; 
but, in early childhood at least, the patients should, if possible, 
be kept under observation, in order that recurrence of deformity 
may be prevented. 

Arthrodesis is also performed at the knee and at the elbow- 
joints and wrist-joints for the purpose of fixing the part in a useful 
attitude. The operation is, of course, limited to cases of hopeless 
paralysis, and it is more satisfactory to the older than the younger 
class of patients, because the liability to recurrence of deformity 
is less. Arthrodesis at the shoulder- joint is of service when the 
humeroscapular muscles are paralyzed, especially in those cases 
in which the muscles that move the scapula retain their power, 
since anchylosis adds to the effectiveness of the arm muscles. 
The joint may be opened by an incision along the anterior lower 



DEFORMITIES OF THE FOOT 843 

border of the deltoid. The cartilaginous surfaces are removed, 
and the humerus is then fixed in close contact with the glenoid 
surface of the scapula by a drill or by sutures until union is firm. 
In most instances, however, the transplantation of the trapezius 
muscle is to be preferred. 



INDEX. 



Abduction, forcible, in treatment of 
coxa vara, 560 
of fracture of neck of femur, 562 
persistent, in weak foot, 692 
Abscess complicating Pott's disease, 
29 
pelvic, in tuberculous disease of 

spine in lower region, 45 
in tuberculous disease of hip-joint, 
378 
significance of, 379 
treatment of, 380 
of knee-joint, 426 
treatment of, 426 
Absence of clavicle, 232 
of patella, 443, 444 
of ribs, 231 
of vertebrae, 231 
Achillobursitis, 730 
anterior, 730 
etiology of, 730 
pathology of, 731 
posterior, 732 
symptoms of, 730 
treatment of, 731 
Achillodynia,732. See Achillobursitis. 
Achondroplasia, 505. See Chondro- 

dystrophia. 
Acquired cerebral paralvsis of child- 
hood, 623 
displacement of patella, 444 
genu recurvatum, 440 
luxation of clavicle, 236 
talipes, 755, 813 
calcaneovalgus, 830 
treatment of, 830 
calcaneovarus, 830 
treatment of, 830 
calcaneus, 822 

deformity in, development of, j 

823 
symptoms of, 823 
treatment of, 824 
Judson brace in, 824 
operative, 825 

Whitman's operation in, 828 ! 

Willett's operation in, 826 j 

deformity in, development of, 814 ! 

diagnosis of, differential, from j 

congenital tstlipes, S15 



Acquired talipes equinovalgus, 831 
treatment of, 832 
equino varus, 831 

treatment of, 831 
equinus, 815 
etiology of, 816 
symptoms of, 817 
treatment of, 818 
arthrodesis in, 821 
immediate correction of de- 
formity in, 818 
Thomas' wrench, 819 
tonic effect of, 820 
manipulation in, 818 
Shaffer extension shoe in, 818 
etiology of, 813 
simple valgus, 832 
torticollis, 642, 648 
Acromegalia, 513 

diagnosis of, 513 
Actinomycosis of spine, 128 
Active congestion in treatment of joint 

disease, 262 
Acute anterior poliomyelitis, 598 
epiphysitis at hip-joint, 399 
infectious arthritis of hip-joint, 399 
osteomyelitis, 277 
suppurative arthritis in infancy, 274 
synovitis of knee, 424 
tenosynovitis at wrist-joint, 480 
tuberculous arthritis, 276 
Adolescents, kyphosis of, 140, 226 
Adults, traumatic coxa vara in, 565 

tuberculous hip disease in, 377 
Amputation in treatment of tuber- 
culous disease of knee-joint, 430 
in tuberculous disease of hip-joint, 
388 
Anchylosis, 293 
etiology of, 293 
pathology of, 293 
prevention of, 293 
treatment of, 293 

forcible correction in, 295 
operative exploration in, 296 
passive motion in, 294 
Ankle, sprain of, 459 
chronic, 462 

treatment of, 462 
symptoms of, 459 
treatment of, 459 
strapping in, 460 



846 



INDEX 



Si e 



Ankle-joint, arthritis of, infectious, 
465 
diseases and injuries of, 449 
other affections of, 465 
tenosynovitis at, 463 
treatment of, 463 
tuberculous, 464 
disease of, 449 

age at incipiency of, 450 
statistics of, 450, 451 
astragalonavicular disease in, 

453 
deformity in, 452 

reduction of, 455 
diagnosis of, 453 
etiology of, 450 
pathology of, 449 
physical examination in, 452 
prognosis in, 457 

statistics of, 457 
situation of, 450 

statistics of, 450 
statistics of, 449 
subastragaloid disease in, 453 
symptoms of, 451 
treatment of, 455 
operative, 456 
Ankles swelling about, 465 
Anterior curvature of tibia, 595 
dislocation at hip-joint, 524 
displacement of tibia, 442. 

Genu recurvatum, congenital, 
metatarsalgia, 721 
poliomyelitis, acute, 598 
age of onset in, 599 

statistics of, 599 
deformities of neck in, 607 
deformity in, 604 
reduction of, 616 
secondary, 608, 609 
of trunk in, 607 
of upper extremity, 607 
diagnosis of, 601 

from diphtheritic paralvsis, 

603 
from joint disease, 602 
from multiple neuritis, 602 
from obstetrical paralvsis, 

603 
from other forms of 

paralysis, 602 
from paralysis of cerebral 

origin in childhood, 602 
from Pott's paraplegia, 

602 
from pseudoparalysis, 603 
from rheumatism, 602 
from spastic spinal paralv- 
sis, 602 
etiology of, 599 

paralysis of different muscles 
in, effect of, upon function, 
604 
distribution of, 600 



Anterior poliomyelitis, acute, pathol- 
ogy of, 598 
prognosis in, 603 

electrical test in, 603 
retardation of growth in, 608, 

609 
symptoms of, 600 
treatment of, 610 
mechanical, principles of, 610 
operative, 616 

arthrodesis in, 620 
Hoffa's, for paralysis of 

deltoid muscle, 618 
nerve grafting in, 620 
osteotomy in, 620 
reduction of deformity in, 

tendon transplantation in, 

618 
transplantation of Sar- 
torius muscle in, 619 
of paralysis of anterior mus- 
cles of leg, 610 
of posterior muscles of leg, 
611 
of arm, 616 
of muscles of hip, 614 
of paralytic scoliosis, 616 
of thigh muscles, 612 
Anteroposterior contour of spine in 
lateral curvature, 155 
deformities of spine, 224 
kyphosis, 224 

treatment of, 226 
lordosis, 228 

treatment of, 229 
Aran-Duchenne type of progressive 

muscular atrophy, 633 
Arborescent synovial tuberculosis, 255 
Arm, paralysis of, obstetrical, 482 

treatment of, 483 
Arthrectomy in treatment of tuber- 
culous disease of knee- 
joint, 427 
results of, 428 
Arthritis of ankle-joint, infectious, 465 
atrophic, 284 

complicating diphtheria, 273 
infectious diseases, 273 
prognosis in, 273 
treatment of, 27 
scarlatina, 273 
typhoid fever, 273 
deformans, 403 
symptoms of, 404 
treatment of, 404 
gonorrhoeal, 270 
distribution of, 270 
in infancy, 272 
symptoms of, 270 
treatment of, 272 
varieties of, 271 
of hip-joint, acute, 399 
symptoms of, 399 



INDEX 



847 



Arthritis of hip-joint, acute, treat- 
ment of, 399 
gonorrhceal, 401 
subacute, 400 
in infancy, acute, 274 
puerperal, 272 
rheumatoid, 284 
of spine, infectious, 133 
of suboccipital region of spine, 133 
suppurative, in infancy, 274 
etiology of, 274 
prognosis of, 275 
symptoms of, 275 
treatment of, 275 
tuberculous, acute, 276 
Arthrodesis, 620 

in paralytic talipes, 841 
in treatment of acquired talipes 
equinus, 821 
Arthrotomy in congenital dislocation 

at hip-joint, 542 
Articulation, sacroiliac, injury of, 148 
Articulations of upper extremity, dis- 
eases and injuries of, 466 
Astragalectomy in treatment of neg- 
lected talipes, 800 
Astragalonavicular disease, 453 
Asymmetrical development of bodv, 

236 
Ataxia, hereditary, 636 
Atrophic arthritis, 284. See Eheu- 

matoid arthritis. 
Atrophy of bone, 244 

muscular, myelopathic form of, 633 

progressive, 633 
in tuberculous disease of hip-joint, 
313 
Brackett's statistics in, 314 
causes of, 314 
Attitude, change in, in Pott's disease, 
28 
rhachitic, 131, 502 
in treatment of weak foot, 699 
in tuberculous disease of spine in 
lower region, 39, 40 



Back, flat, 224 

hollow round, 223, 224 

knee, 440. See Genu recurvatum. 

pain in lower portion of, 142 ja 

treatment of, 143 
round, 223 
Bandage, plaster, in treatment of 
tuberculous disease of knee-joint, 
417 
of hip-joint, of spine. See Spicas, 
plaster jacket, etc. 
Baseball finger, 496 
Bier's treatment of tuberculous dis- 
ease of knee-joint, 425 i 
Bilateral coxa vara, 555 



Bilateral dislocation at hip-joint, 523 

hip disease, 375 
Billroth splint in treatment of tuber- 
culous disease of knee-joint, 419 
Bodv, asymmetrical development of, 
236 
lateral inclination of, in tuberculous 
disease of spine in lower region, 41 
Bone, atrophy of, 244 
hypertrophy of, 245 
Bones and joints of lower extremity, 
deformities of, 569 
operation on, in treatment of 

neglected talipes, 800 
tuberculous disease of, 246 
Bow-leg, 569 
anterior, 595 

symptoms of, 595 
treatment of, 597 
attitude of rest in, 572 
deformity in, measurement of, 591 
outgrowth of, 572 
predisposition to, 570 
symptoms of, 591 
time of onset of, 570 
treatment of, 592 
by braces, 592 
expectant, 592 
operative, 594 
Brace, anterior shoulder, 77 

caliper, in treatment of tubercu- 
lous disease of knee-joint, 420 
Judson's, in treatment of acquired 
talipes calcaneus, 824 
of infantile club-foot, 773 
Knight spinal, 217 
in lateral curvature of spine, 216 
retention, in treatment of infantile 

club-foot, 777 
Taylor, in treatment of infantile 
club-foot, 777 
of Pott's disease, 76 
Thomas' knee, in treatment of 
tuberculous disease of knee-joint, 
420 
in treatment of bow-leg, 592 
of infantile club-foot, 773 
of knock-knee, 585 
of lateral curvature of spine, 216 
of weak foot, 703 
Whitman's, in treatment of weak 
foot, 703 , i 

Brachial plexus, obstetrical injury to, 

repair of, 487 
Bunion, 744 

Bursa, pretibial, enlargement of super- 
ficial, 440 
Bursse and cysts in popliteal region, 

440 
Bursitis, gluteal, 402 
iliopsoas, 402 
prepatellar, 439 

treatment of, 439 
pretibial, 439 



848 



INDEX 



Bursitis, pretibial, symptoms of, 439 
treatment of, 440 
at shoulder-joint, chronic, 479 
treatment of, 403 



Galcaneobursitis, 733 

treatment of, 734 
Caput quadratum in rhachitis, 500 
Carcinoma of femur, 403 

of spine, 126 
Caries, dry, 256 

sicca, 256 
Cerebral paralysis of childhood, 623 
acquired, 623 

deformities in, 628 
disability in, 628 
loss of growth in, 628 
paralysis in, 627 
congenital, 623 
paralysis in, 626 
weakness in, 626 
deformities in, 627 
distribution in, 623 
statistics of, 623 
etiology of, 623 
of intrauterine origin, 624 
occurring during labor, 624 
pathology of, 623 
symptoms of, general, 625 
mental, 626 
motor, 625 
treatment of, 629 
of hemiplegia, 629 
of paraplegia, 631 
Cervical opisthotonos, 663 

ribs, 231 
Charcot's disease, 290 
diagnosis of, 292 
distribution of , 291, 292 
pathology of, 291 
symptoms of, 292 
treatment of, 292 
Chest, deformities of, 232 
flat, 232 

treatment of, 232 
funnel, 235 

minor deformities of, 235 
pigeon, 233 

treatment of, 234 
Childhood, cerebral paralysis of, 623 
osteomalacia in, 509 
strains and injuries of knee in, 434 
weak foot in, 694 
Chondrodystrophia, 505 
etiology of, 506 
pathology of, 506 
prognosis of, 506 
treatment of, 506 
Chronic bursitis at shoulder-joint, 47 

synovitis of knee, 435 
Clavicle, absence of, 232 
acquired luxation of, 236 



Clavicle, acquired luxation of, treat- 
ment of, 236 
defect of, 232 
subluxation of, 236 
treatment of, 236 
Club-foot, congenital, 755 
anatomy of, 756 
symptoms of, 766 
treatment of, 767 
Club-hand, 491 
etiology of, 491 
statistics of, 492 
treatment of, 493 
varieties of, 491 
Compensatory deformity in lateral 
curvature of spine, 165 
in Pott's disease, 28 
Congenital and acquired affections 
leading to general distortions, 498 
cerebral paralysis of childhood, 623 
contraction of fingers, 494 
treatment of, 494 
at knee, 448 
deficiency of foot, 811 
deformities of elbow, 489 

of foot associated with defective 

development, 809 
at knee, 447 
at wrist, 491 
dislocation at hip-joint, 515 
anterior, 524 

symptoms of, 524 
bilateral, 523 

symptoms of, 523 
diagnosis of, 524 
etiology of, 520 
pathology of, 516 
supracotyloid, 524 
symptoms of, 521 

general, 523 
treatment of, 526 
arthrotomy in, 542 

description of, 543 
in infancy, 540 
Lorenz's operation in, 527 
description of, 527 
prognosis of, 537 
older subjects, 539 
open operation in, 544 

description of, 544 
of osteotomy in, 543 
palliative, 549 
reduction, 531 

in two sittings, 531 
in the young, 531 
variations in, 540 
unilateral, 521 
svmptoms of, 521 
of shoulder, 482 

reduction of deformity in, 484 
displacement of patella, 444 

of phalanges, 495 
elevation of scapula, 229 
genu recurvatum, 442 
hypertrophy of foot, 811 



INDEX 



849 



Congenital oedema of feet, 812 
subluxation of hip, 549 
talipes, 755 

calcaneovalgus, 808 
calcaneovarus, 808 
calcaneus, 807 
equinocavus, 808 
equinus, 807 
etiology of, 756 
valgocavus, 808 
valgus, 807 
varus, 806 
torticollis, 642, 643 
weakness in cerebral paralysis of 
childhood, 623 
Constricting bands of foot, 812 
Contracted foot, 716 
etiology of, 716 
symptoms of, 717 
treatment of, 719 
operative, 720 
Contraction, Dupuytren's, 496 
etiology of, 496 
pathology of, 496 
symptoms of, 497 
treatment of, 497 
at knee, congenital, 448 
psoas, in tuberculous disease of 
spine in lower region, 40 
Coxa valga, 568 
vara, 550 
bilateral, 555 

deformity in, mechanical predis- 
position to, 551 
diagnosis of, 556 
etiology of, 551 
other varieties of, 556 
pathology of, 550 
symptoms of, 553 

mechanical effects, 553 
physical effects, 554 
traumatic, 562 
in adult life, 565 
treatment of, 563 
treatment of, 558 
operative, 560 

cuneiform osteotomy in, 

560 
forcible abduction in, 560 
linear osteotomy in, 560 
Cramp, muscular, of leg, 434 
Craniotabes in rhachitis, 500 
Crepitus, scapular, 236 
Cretinism, 506 
Cubitus valgus, 489 
in rhachitis, 501 
varus, 489 

in rhachitis, 501 
Cuneiform osteotomy in treatment of 
anterior bow-leg, 597 
of coxa vara, 560 
of knock-knee, 589 
of neglected talipes, 800 
Curvature of spine, lateral, 149 



Cysts, bursse and, in popliteal region, 
440 
of femur, 403 



Defect of clavicle, 232 
Deformity in acquired talipes, de- 
velopment of, 814 
in acute anterior poliomyelitis, 604 

reduction of, 616 
of bones of lower extremity, 569 
in bow-leg, measurement of, 591 
outgrowth of, 572 
predisposition to, 570 
in cerebral paralysis of childhood, 

627 
of chest, 232 
minor, 235 
compensatory, in lateral curvature 
of spine, 165 
in Pott's disease, 29 
correction of, by femoral osteotomy 
in tuberculous disease of hip- 
joint, 390 
in coxa vara, mechanical predis- 
position to, 551 
development of, in acquired talipes, 
814 
calcaneus, 823 
of elbow, congenital, 489 
of foot, 665, 752 

compound, 753 
functional pathogenesis of, 238 

Wolff's law of, 238 
hysterica], 638 
at knee, congenital, 447 
in knock-knee, measurement of, 
581 
outgrowth of, 572 
predisposition to, 570 
secondary, 578 
in lateral curvature of spine, 172 

prevention of, 179 
of legs with weak foot in childhood, 

695 
and malformations of knee, 443 
of neck in acute anterior poliomy- 
elitis, 607 
of other parts caused by tubercu- 
lous disease of hip-joint, 396 
overcorrection of, in torticollis, 655 
in Pott's disease, 17 
compensatory, 28 
muscular, 28 
rapid correction of, in treatment of 

neglected talipes, 781 
rectification of, in treatment of in- 
fantile talipes, 768 
reduction of, in congenital dislo- 
cation of shoulder, 484 
in resistant cases of tubercuolus 
of hip- joint, 388 



54 



850 



INDEX 



Deformity, reduction of, in treatment 
of tuberculous disease of knee- 
joint, 417 
in rhachitis, 500 

secondary, of acute anterior polio- 
myelitis, 608, 609 
in neglected talipes, 789 
of spine, anteroposterior, 224 
Sprengel's, 229 

of trunk in acute anterior poliomye- 
litis, 607 
in tuberculous disease of ankle- 
joint, 452 
reduction of, 455 
of upper extremity, 482 

in acute anterior poliomyelitis, 
607 
in weak foot, 679 
at wrist, congenital, 491 
Deviation, lateral, in lateral curvature 

of spine, 151 
Diagnosis of acute anterior poliomy- 
elitis, 601 
of Charcot's disease, 292 
of congenital dislocation of hip- 
joint, 524 
of coxa vara, 556 

differential, between congenital and 
acquired talipes, 815 
of lumbar Pott's disease in in- 
fancy, 50 
from acute rhachitis, 50 
from scurvy, 50 
of tuberculous disease of spine, 
46-65 
of disease of spine, landmarks in, 

34 
of hysterical hip, 637 
of lateral curvature of spine, 174 
mobility in, 175 
posture in, 174 
of malignant disease of spine, 127 
of sacroiliac disease, 146 
of torticollis, 651 

of tuberculous disease of ankle- 
joint, 453 
of bones and joints, 259 
of hip-joints, 326 
of knee-joints, 415 
of spine, 65 
of typhoid spine, 132 
of weak foot, 687 
Disabilities of foot, 665 
Diseases and injuries of ankle-joint, 
449 
of articulations of upper extrem- 
ity, 466 
Dislocation of hip-joint, spontaneous, 
400 
of shoulder, congenital, 482 
recurrent, 487 
treatment of, 487 
Displacement of peronei tendons, 746 
treatment of, 746 



Distortions of fingers, 495 

of limb in tuberculous disease of 

hip- joint, 307 
rhachitic, general, 598 
Doigt a Ressort, 495 
Drop-finger, 496 
Dry caries, 256 
Dupuytren's contraction, 496 

etiology of, 497 

pathology of, 496 

symptoms of, 497 

treatment of, 497 
Dysbasia angiosclerotica, 735 
Dystrophy, muscular, 634 



Effusion at knee, quiet, 438 
Elbow, deformities of, acquired, 
489 
congenital, 489 
Elbow-joint, tuberculous disease of, 
470 
age at incipiency of, 470 

statistics of, 470 

pathology of, 470 

symptoms of, 471 

treatment of, 471 

excision in, 473 

operative, 473 

reduction of deformity in, 
473 
Electrical test in prognosis of acute 

anterior poliomyelitis, 603 
Elongation of ligamentum patella?, 
447 
etiology of, 447 
symptoms of, 447 
treatment of, 447 
Enlargement of superficial pretibial 

bursa, 440 
Epiphysitis at hip-joint, acute, 399 
symptoms of, 399 
treatment of, 399 
Erythromelalgia, 734 
Excision of hip-joint in tuberculous 
disease, 384 
in treatment of tuberculous disease 
of knee-joint, 428 
results of, 429 
Exercise in treatment of knock-knee, 
583 
of lateral curvature of spine, 184, 
200 
in muscle building, 207 
of weak foot, 699 
Exostoses of foot, 746 
Extra-articular hip-joint disease, 
401 
tuberculous disease of knee-joint, 
426 
operative intervention in,426 
treatment of, 426 



INDEX 



851 



Femur, bending of neck of, '550. See 

Coxa vara, 
carcinoma of, 403 
cysts of, 403 
depression of neck of, 550. See 

Coxa vara, 
fracture of neck of, 562 

in adult life, 565 
incurvation of neck of, 550. See 

Coxa vara, 
partial separation of epiphysis of 

head of, in adolescence, 565 
sarcoma of, 403 
and tibia, changed relations of, in 

knock-knee, 578 
traumatic separation of epiphysis 

of head of, 564 
Finger, baseball, 496 

contraction of, congenital, 494 

treatment of, 494 
distortions of, 495 
drop-, 496 
jerking, 495 

etiology of, 495 

treatment of, 496 
mallet, 496 
snapping, 495 

etiology of, 495 

treatment of, 496 
trigger, 495 

etiology of, 495 

treatment of, 496 
webbed, 495 

etiology of, 495 

treatment of, 495 
Flat back, 224 

chest, 232 
Foetal rhachitis, 505 
Foot in activity, 668 
arches of, 665 

club-, non-deforming, 716. See Con- 
tracted foot, 
considered as a mechanism, 676 
constricting bands of, 812 
contracted, 716 

etiology of, 716 

symptoms of, 717 

treatment of, 719 
operative, 720 
deficiency of, congenital, 811 
deformities of, 752 

compound, 753 

congenital, associated with de- 
fective development, 809 
disabilities and deformities of, 665 
exostoses of, 746 
flat-, 679 

functions of muscles of, 675 
general description of, and its func- 
tions, 665 
hollow, 716 

hypertrophy of, congenital, 811 
improper postures of, 669 



Foot, movements of, 670 • 
oedema of, congenital, 812 
as a passive support, 667 
splay-, 679 
tables of relative strength of muscles 

of, 676 
weak, 679 

in childhood, 694 
symptoms of, 694 
weak ankles in, 694 
deformity of legs with, 695, 697 
general weakness in, 695 
irregular forms of, 695 
outgrown joints in, 695 
out-toeing and in-toeing in, 694 
diagnosis of, 687 
attitudes in, 687 
bearing surface in, 689 
contour in, 688 
distribution of weight and 

strain, 687 
range of motion in, 689 
etiology of, 683 
extreme types of, 692 
persistent abduction, 692 
pes planus, 692 
limitation of motion and mus- 
cular spasm in, 692 
pathology of, 683 
rigid, 706 

functional use in overcorrected 

attitude, 708 
treatment of, 706 
adjuncts in, 713 
forcible overcorrection in, 707 
operative, 714 
plaster strapping in, 713 
systematic manipulation in, 

709 
Thomas', 713 
varieties of, 712 
symptoms of, 685 
treatment of, 697 
attitudes in, 699 
brace in, 703 

construction of, 701 
positive action of, 704 
exercises in, 699 
plaster cast in, 702 
raising inner border of shoe in, 

699 
the shoe in, 698 
support in, 700 
varieties of, 691 
Forcible abduction in treatment of 
coxa vara, 560 
correction by reverse leverage in 
treatment of tuberculous disease 
of knee-joint, 418 
Fracture of metatarsal bones, 746 
of neck of femur, 562 
in adult life, 565 
of spine, 129 
Fragilitas ossium, 507 
Friedreich's disease, 636 



852 



INDEX 



Function, impairment of, in Pott's 

disease, 28 
Functional affections of joints, 636, 
639 
pathogenesis of deformity, 238 

Wolff's law of, 238 
results of treatment of tuberculous 
disease of hip-joint, 432 
Funnel chest, 235 



Gait in tuberculous disease of spine in 

lower region, 39 
General rhachitic distortions of lower 

limbs, 597 
Genu recurvatum, acquired, 440 
etiology of, 441 
symptoms of, 441 
treatment of, 442 
congenital, 442 
etiology of, 443 
treatment of, 443 
valgum, deformity in, outgrowth of, 
572 
etiology of, 570 
pathology of, 581 
time of onset, 570 
treatment of, 583 
expectant, 583 
operative, 587 
unilateral, 580 
varum, 590 

deformity in, outgrowth of, 572 
symptoms of, 591 
time of onset of, 570 
treatment of, 592 
by braces, 592 
expectant, 592 
operative, 594 
Gluteal bursitis, 402 
Gonorrhceal arthritis, 270 
distribution of, 270 
of hip-joint, 401 
in infancy, 272 
purulent form of, 271 
serofibrinous form of, 271 
serous form of, 271 
symptoms of, 270 
treatment of, 272 
rheumatism, 270. See Gonorrhceal 
arthritis, 
of spine, 133 
Gout, 288 

Growth, retardation of, in paralytic 
affections, 625 
in tuberculous disease of hip-joint, 
317 



HvEMARTHROSIS, 290 

Hematoma of sternomastoid muscle, 
646 



Haemophilia, 289 

treatment of, 290 
Hallux nexus, 735 
rigidus, 735 
etiology of, 736 
treatment of, 736 
valgus, 740 

etiology of, 741 
pathology of, 740 
symptoms of, 741 
treatment of, 741 
operative, 742 
varus, 738 

treatment of, 739 
Hammer-toe, 744 
symptoms of, 745 
treatment of, 745 
Harrison's groove in rhachitis, 500 
Heberden's nodosities in osteoarthri- 
tis, 283 
Heel, painful, 733 

treatment of, 734 
Hemorrhage into joints, 289, 290 
Hereditary ataxia, 636 
High hip in lateral curvature of spine, 
156 
shoe in treatment of lateral curva- 
ture of spine, 221 
shoulder in lateral curvature of 
spine, 156 
Hip, change in contour of, in tuber- 
culous disease of hip-joint, 313 
disease, 298 
hysterical, 637 
snapping, 549 

subluxation of, congenital, 549 

Hip-joint, acute epiphysitis at, 399 

infectious arthritis of, 399 

disease, extra-articular, 401 

dislocation at, congenital, 515 

anterior, 524 

s)'inptoms of, 524 
bilateral, 523 

symptoms of, 523 
diagnosis of, 524 
etiology of, 520 

hereditary influence in, 520 
pathology of, 516 
supracotyloid, 524 
symptoms of, 521 

general, 523 
treatment of, 526 
arthrotomy in, 542 

description of, 543 
in infancy, 540 
Lorenz, description of, 527 
operation in, 527 
prognosis of, 537 
older subjects, 539 
open operation in, 544 
description of, 544 
statistics of, 546 
osteotomy in, 543 
palliative, 549 



INDEX 



853 



Hip-joint, dislocation at, congenital, 
treatment of, reduction, 
531 
in two sittings, 531 
in young, 531 
variations in, 540 
unilateral, 521 
symptoms of, 521 
excision of, in tuberculous disease, 

384 
gonorrhceal arthritis of, 401 
malignant disease of, 403 
non-tuberculous affections of, 398 
osteoarthritis of, 403 
symptoms of, 404 
treatment of, 404 
spontaneous dislocation of, 400 
subacute arthritis of, 400 
traumatisms at, 398 
treatment of, 398 
tuberculous disease of, 298 
abscess in, 378 

significance of, 379 
treatment of, 380 

exploratory operations in, 
382 
actual lengthening of limb in, 
318 
shortening of limb in, 316 
in adult, 377 
age at incipiency, 302 
amputation in, 388 
bilateral, 375 

treatment of, 376 
causes of death, 392 
combined with disease of other 

parts, 376 
correction of deformity by 

femoral osteotomy, 390 
details of 1000 cases of, 330 
diagnosis of, differential, 326 
distortion of limb in, 307 

apparent lengthening, 307 
shortening, 310 
examination in, method of, 320 

physical, 320 
excision of hip in, 384 
Koenig's method of, 384 
statistics of, 386, 387 
table of functional results of, 
387 
history of case of, 320 
in infancy, 377 
Koenig's statistics of, 310 
local signs of, 325 
, measurements in, 321 

method of estimating degree of 
distortion of limb 
in, 322 
Kingsley's table, 

325 
Lovett's table, 323 
of recording case of, 329 
formulae used, 330 



Hip-joint, tuberculous disease of, 
mortality in, 391 
natural cure in, 310 
prognosis of, 391 

as to function, 394 
reduction of deformity in re- 
sistant cases of, 388 
sex affected in, 302 
side affected in, 303 
sinuses in, 382 

treatment of, 382 
symptoms of, 303 
atrophy as, 313 
change in contour of hip as, 

313 
distortion of limb as, 307 
general, 319 
debility 319 
fever, 320 
limp as, 303, 304 
night cry as, 304 
stiffness as, 305 
treatment of, 332 

application of plaster spica 

bandage in, 350 
during stage of recovery, 371 
immediate reduction of de- 
formity in, 353 
Lorenz spica bandage in, 351 
mechanical, 333 

application of traction 

splint in, 338 
high shoe in, 338 
perineal bands in, 338 
splinting in, 334 
Taylor's method of trac- 
tion in, 336 
traction hip splint for, 
334 
plasters in, 336 
straps for, 336 
by plaster bandage, 349 
practical combination of 
traction, splinting , and 
stilting in, 361 
reduction of deformity in, 
immediate, 353 
lateral traction in, 358 
by Thomas' method, 346 
by traction brace in, 340 
by weights and pulleys, 
350 
Marsh's appliance 
for, 356 
relative efficiency of traction 
hip splint in, 341 
and splinting in, 359 
removal of direct pressure 

in, 360 
stilting in, 334, 360 
Thomas', 343 
brace in, 344 

modifications of 348 
traction in, 334 



854 



INDEX 



Hoffa's treatment for paralysis of del- 
toid muscle in acute anterior polio- 
myelitis, 618 

Hollow foot, 716. See Contracted 
foot. 

Hyperesthesia of skin in neurotic 
spine, 143 

Hyperplasia of fatty tissue within 
knee-joint, 437 

Hypertrophy of bone, 245 

Hysterical club-foot, 638 
deformities, 638 
hip, 637 

diagnosis of, 637 
joint affections and deformities, 636 



spine, 144 

symptoms of, 145 
treatment of, 145 



Idiopathic osteopsathyrosis, 507 
Iliopsoas bursitis, 402 
Incidental lateral curvature of spine, 
166 
synovitis of knee, 438 
Infancy, acute arthritis in, 274 
gonorrhoeal arthritis in, 272 
lumbar Pott's disease in, peculiar- 
ities of, 50 
tuberculous hip disease in, 377 
Infantile paralysis, 598. See Acute 
anterior poliomyelitis, 
scorbutus, 506 
pathology of, 507 
symptoms of, 507 
treatment of, 507 
Infectious arthritis of ankle-joint, 465 

osteomyelitis, 277 
Injuries, diseases and, of ankle-joint, 
449 
of articulations of upper extrem- 
ity 466 
of knee, 437 

in childhood, 434 
of sacroiliac articulation, 148 
of spine, 128 
of tibial tubercle, 440 
Intermittent limp, 735 
Internal derangement of knee-joint, 

436 
Irregular forms of torticollis, 663 



Jerking finger, 495 

Joint affections, hysterical, 636 

treatment of, 638 
Joints, bones and, tuberculous disease 
of, 246 
double, in rhachitis, 500 



Joints, functional affections of, 636 
hemorrhage into, 289, 290 
inflammation of, gonorrhoeal 270 
neurotic, 639 

non-tuberculous diseases of, 266 
pelvic, relaxation of, 142 
syphilitic diseases of, 266 
treatment of, 269 
pain and swelling of, 267 
tuberculous disease of, other forms 
of, 254 
Judson's brace in treatment of ac- 
quired talipes calcaneus, 824 
of infantile club-foot, 773 



Kingsley's table for estimating de- 
gree of distortion of limb in tuber- 
culous disease of hip- joint, 325 
Knee, back, 440. See Genu recurva- 
tum. 
contraction at, congenital, 448 
prognosis of, 448 
treatment of, 448 
deformities at, congenital, 447 
displacement of a semilunar carti- 
lage of, 436 
housemaid's, 439 
treatment of, 439 
Knee-joint, hyperplasia of fatty tissue 
within, 437 
injury of, 437 

in childhood, 434 
loose bodies in, 436 
non-tuberculous affections of, 434 
deformities of, 434 
pathology of, 406 
primary distortions of, 411 
prognosis in, 431 
statistics of, 431 
Gibney's, 431 
secondary distortions of, 412 
statistics of, 409 

age at incipiency, 409 
on course and outcome of, 
431 
symptoms of, 409 
synonyms of, 406 
synovial tuberculosis, 427 

treatment of, 427 
treatment of, 416 
accessory, 424 

Bier's treatment of, 425 
cautery as, 424 
ichthyol ointment as, 424 
iodoform emulsion injec- 
tions as, 424 
x-rays as, 424 
amputation in, 430 
arthrectomy in, 427 
results of, 428 
statistics of, 428 



INDEX 



855 



Knee-joint, non-tuberculous, deformi- 
ties of, treatment of, Bill- 
roth splint in, 419 
during convalescence, 425 
excision in, 428 
results of, 429 
forcible correction by re- 
verse leverage in, 418 
functional results of, 432 

statistics of, 431 
mechanical, 420 
caliper brace in, 423 
Thomas' knee brace in, 420 
operations for relief of final 

deformity in, 430 
plaster bandage in, 417 
reduction of deformity in, 

417 
traction in, 418 
malformations of, 443 
other deformities of, 443 
quiet effusion at, 438 
snapping, 447 

treatment of, 448 
strains of, in childhood, 434 
synovitis of, acute, 434 
causes of, 435 
chronic, 435 
incidental, 438 
painless, 438 
recurrent, 435 
tuberculous diseases of, 406 
abscess in, 426 

Koenig's statistics of, 426 
treatment of, 426 
actual lengthening of limb in, 
414 
statistics of, 414 
shortening in, 414 
statistics of, 432 
deformity in, 432 

statistics of, 432 
diagnosis of, 415 

from acute epiphysitis, 415 
from Charcot's disease, 416 
from hsemarthrosis, 415 
from hysterical joint, 416 
from infectious arthritis, 415 
from injury of knee, 415 
from osteoarthritis, 416 
from rheumatism, 416 
from rheumatoid arthritis, 

416 
from sarcoma, 416 
from synovitis, 415 
distortion in, primary, 411 

secondary, 412 
etiology of, 409 
extra-articular, 426 

operative intervention in, 426 
treatment of, 426 
mortality in, 431 
causes of, 433 
influence of age on, 432 



Knee-joint, tuberculous diseases of, 
mortality in, statistics of, 431, 432 
Knock-knee, 569 

attitude in, accommodative, 587 

of rest in, 572 
changed relation of femur and tibia 

in, 578 
combined with bow-legs, 580 

with general rhachitic distortion, 
580 
deformity in, measurements of, 
581 
outgrowth of, 572 
predisposition to, 570 
secondary, 578 
etiology of, 570 
gait in, 579 
pathology of, 581 
time of onset of, 570 
treatment of, 583 
by braces, 585 

duration of, 587 
exercise in, 583 
expectant, 385 
Lorenz's, 589 
manipulation in, 583 
operative, 587 
osteoclasis in, 589 
osteotomy in, 587 
cuneiform, 589 
plaster bandage in, 587 
posture in, 583 
Thomas brace in, 585 
Wolff's, 589 
unilateral, 580 
Koenig's statistics of abscess in tuber- 
culous disease of knee-joint, 
426 
of non-tuberculous affections of 

hip-joint, 398 
of tuberculous disease of hip-joint, 
310 
Kyphosis, 224 

of adolescents, 140, 226 
postural, 225 
in rhachitis, 500 
treatment of, 226 



Late rickets, 504 

Lateral curvature of spine, 149 

changes in anteroposterior con- 
tour in, 155 
compensatory deformity in, 162 
congenital, 167 
diagnosis of, 174 
posture in, 174 
mobility in, 175 
due to occupation, 167 
etiology of, 161 
hereditary influence in, 169 
high hip in, 156 



856 



INDEX 



Lateral cuivature of spine, high shoul- 
der in, 156 
incidental, 166 
lateral deviation in, 151 
occupation as inducing deform- 
ity, 170 
statistics of, 170 
pathology of, 157 
prevention of deformity , in 

179 
records of, 175 
relative frequency of, 161 
statistics of, 161 
as to age, 162 
as to sex, 162 
rhachitic, 168 

statistics of, 168, 169 
rotation in, 151 
secondary to deformity else- 
where, 165 
to disease within thoracic 

walls, 165 
to paralysis, 165 
symptoms of, 173 
treatment of, 179 
braces in, use of, 216 
duration of, 222 
exercises in, 184-200 
general, 185-200 
muscle building, 207 
self-correcting, 201 
Teschner's, 185 
forcible correction of deform- 
ity in, 218 
combined with fixa- 
tion, 219 
general, 221 
high shoe in, 221 
posture in, 184 

and support during recum- 
bency in, 221 
removal of superincumbent 
weight, 214 
by self-suspension, 214 
Volkmann seat in, 221 
varieties of deformity in, 172 
statistics of, 172 
Leg, muscular cramp of, 434 
Leverage, reverse, forcible correction 
by, in treatment of tuberculous dis- 
ease of knee-joint, 418 
Ligaments, spinal, rupture of, 129 
Ligamentum patellae, elongation of, 
447 
etiology of, 447 
symptoms of, 447 
treatment of, 447 
Limb, actual lengthening of, in tuber- 
culous disease of hip- 
joint, 318 
of knee-joint, 414 
of hip-joint, 316 
shortening of, in tuberculous dis- 
ease of knee-joint, 414 



Limb, apparent lengthening of, in 
tuberculous disease of hip- 
joint, 307 
shortening of, in tuberculous dis- 
ease of hip-joint, 310 
distortion of, in tuberculous disease 
of hip-joint, 307 
of knee-joint, 411, 412 
method of estimating degree of dis- 
tortion of, in tuberculous disease 
of hip-joint, 322 
Limp, intermittent, 735 

as symptom of tuberculous disease 
of hip-joint, 304 
Linear osteotom}' in treatment of coxa 

vara, 560 
Lipoma arborescens, tuberculous joint 

disease in, 255 
Locahzed osteomyelitis, 279 
Loose bodies in knee-joint, 634 
Lordosis, 228 

treatment of, 229 

in tuberculous disease of spine in 
lower region, 39 
Lorenz operation in treatment of con- 
genital dislocation at hip-joint, 
527 
treatment of knock-knee, 589 
Lovett's table for estimating degree of 
distortion of limb in tuberculous 
disease of hip-joint, 323 



Malleotomy in treatment of neglected 

talipes, 789 
Mallet finger, 496 

Manipulation in treatment of acquired 
talipes equinus, 818 
of torticollis, 654 
Manual correction, forcible, in treat- 
ment of neglected talipes, 
782 
in treatment of infantile club- 
foot, 779 
Measurements in tuberculous 



of hip-joint, 321 
Mechanical treatment of infantile 

talipes, 769 
Melos-extremity, 134 
Metatarsal arch, anterior, 723 
weakness of, 721 
bones, fracture of, 746 
Metatarsalgia, anterior, 721 
etiology of, 722, 726 
influence of shoe in causing pain 

in, 725 
pathology of, 722 
treatment of, 727 
operative, 729 
Metatarsus varus, 740 
Mollitis ossium, 508 
Morbus coxa?, 298 



INDEX 



857 



Mortality in tuberculous disease of 

hip-joint, 391 
Morton's neuralgia, 721. See Meta- 

tarsalgia, anterior. 
Muscles, pectoral, defective formation 

of, 232 
Muscular atrophy, progressive, 633 
myelopathic form of, 633 
myopathic form of, 634 
deformity in Pott's disease, 28 
dystrophy, 634 

paralysis, pseudohypertrophic, 634, 
635 
diagnosis of, 635 
treatment of, 600 
Myelopathic paralysis, 633 
atrophy, 633 



Nerve grafting in treatment of acute 

anterior poliomyelitis, 620 
Nervous system, diseases of, 598 
Neuralgia, Morton's, 721. See Meta- 
tarsalgia, anterior, 
plantar, 734 

treatment of, 734 
Neuritis, 636 

localized, 663 
Neurotic joints, 639 
spine, 143 

symptoms of, 143 
treatment of, 144 
" Night cry" in Pott's disease, 28 

as symptom of tuberculous dis- 
ease of hip- joint, 304 
Non-deforming club-foot, 716. See 

Contracted foot. 
Non-tuberculous affections of knee- 
joint, 434 
of spine, 126 
deformities of knee-joint, 434 
diseases of joints, 266 



Obstetrical injury to brachial plexus, 
repair of, 487 
paralysis of arm, 482 
Occupation causing lateral curvature 
of spine, 167 
inducing deformity in lateral curva- 
ture of spine, 170 
Ocular torticollis, 663 
(Edema of feet, congenital, 812 
Operations for relief of final deformity 
in tuberculous disease of hip-joint, 
430 
Opisthotonos, cervical, 663 
Osteitis deformans, 140, 510 

local, 511 
Osteoarthritis, 279 



Osteoarthritis, etiology of, 282 
Heberden's nodosities in, 283 
of hip-joint, 403 
symptoms of, 404 
treatment of, 404 
pathology of, 280 
symptoms of, 282 
treatment of, 284 
Osteoarthropathy, hypertrophic, sec- 
ondary, 512 
Ostechondritis, syphilitic, 266 
Osteoclasis in treatment of knock- 
knee, 589 
Osteoclasts in treatment of neglected 

talipes, 794, 796 
Osteomalacia, 508 
in childhood, 509 
local, 510 
treatment of, 509 
Osteomyelitis, acute, 277 
infectious, 277 
localized, 279 
of spine, acute, 127 
infectious, 127 
Osteoperiostitis, syphilitic, 266 
Osteopsathyrosis, idiopathic, 507 
Osteotomy in congenital dislocation at 
hip-joint, 543 
cuneiform in treatment of coxa 
vara, 560 
of neglected talipes, 800 
linear, in treatment of coxa vara, 

560 
secondary in treatment of neglected 

talipes, 802 
in treatment of acute anterior polio- 
myelitis, 620 
of knock-knee, 587 
Overcorrection, forcible, in treatment 

of rigid weak foot, 707 
Overlapping toes, 745 



Paget's disease, 140 
Painful great toe, 735 

toe-joint in older subjects, 737 
heel, 733 
Painless synovitis of knee, 438 
Palliative treatment of congenital dis- 
location at hip-joint, 549 
Paralysis in acute anterior poliomye- 
litis, 600 
of arm, obstetrical, 482 

treatment of, 483 
cerebral, of childhood, 623 
acquired, 623, 627 
after-birth, 624 
deformities in, 628 
disability in, 628 
loss of growth in, 628 
congenital, 623 
paralysis in, 626 



858 



INDEX 



Paralysis, cerebral, of childhood, con- 
genital, weakness in, 626 
deformities in, 627 
distribution of, 623 
statistics of, 623 
etiology of, 623 
of intrauterine origin, 624 
occurring during labor, 624 
pathology of, 623 
prognosis in, 632 
symptoms of, general, 625 
mental, 626 
motor, 625 
treatment of, 629 
of hemiplegia, 629 
of paraplegia, 631 
transplantation of tendons, 
630, 632 
infantile, 598. See Acute anterior 

poliomyelitis, 
muscular, pseudohypertrophic, 634, 

635 
myelopathic, 633 
in Pott's disease, 29 
spastic, 623 
spinal, spastic, 633 
Paralytic torticollis, 663 
Paraplegia, Pott's, 115 
Partial separation of epiphysis of head 

of femur in adolescence, 565 
Patella, absent, 443, 444 

displacement of, acquired, 444 

congenital, 444 
rudimentary, 443, 444 

treatment of, 444 
slipping, 444 
etiology of, 445 
symptoms of, 445 
treatment of, 446 
operative, 446 
Pectus carinatum, 233 

excavatum, 235 
Pelvic joints, relaxation of, 142 
Pelvis, inclination of, 35 
Periarthritis scapulohumeral, 478 
of shoulder, 478 
symptoms of, 478 
treatment of, 479 
Peronei tendons, displacement of, 746 
Persistent abduction in weak foot, 

692 
Pes planus, 692 

Phalanges, displacements of, con- 
genital, 495 
Phelps' operation in treatment of 

neglected talipes, 797 
Pigeon breast in rhachitis, 500 
chest, 233 

in tuberculous disease of spine in 
thoracic region, 52 
toe, 739 
Plantalgia, 734 
Plantar neuralgia, 734 
treatment of, 734 



Plaster bandage in treatment of in- 
fantile club-foot, 769 
of knock-knee, 587 
of tuberculous disease of knee- 
joint, 417 
strapping in treatment of rigid weak 
foot, 713 
Poliomyelitis, anterior, acute, 598 
age of onset in, 599 
statistics of, 599 
deformity in, 604 
causes of, 604 
functional use as cause of, 

606 
gravity, 605 
habitual posture, 605 
muscular action, 605 
deformities of neck in, 607 
reduction of, 616 
secondary, 608, 609 
subluxation, 606 
of trunk in, 607 
of upper extremity in, 
607 
diagnosis of, 601 

from diphtheritic paralysis, 

603 
from joint disease, 602 
from multiple neuritis, 602 
from obstetrical paralysis, 

603 
from other forms of spinal 

paralysis, 602 
from paralysis of cerebral 

origin in childhood, 602 
from Pott's paraplegia, 602 
from pseudoparalysis, 603 
from rheumatism, 602 
from spastic spinal para- 
plegia, 602 
etiology of, 599 

paralysis of different muscles 
in, effects of, upon func- 
tirn, 604 
distribution of, 600 
pathology of, 598 
prognosis in, 603 

electrical test in, 603 
retardation of growth in, 608, 

609 
symptoms of, 600 
treatment of, 610 

mechanical, principles of, 

610 
operative, 616 

arthrodesis in, 620 
Hoffa's, for paralysis of 

deltoid muscle, 618 
nerve grafting in, 620 
osteotomy in, 620 
reduction of deformity in, 

616 
tendon transplantation in, 
618 



INDEX 



859 



Poliomyelitis, anterior, acute, treat- 
ment of, operative, 
transplantation for par- 
alysis of anterior mus- 
cles of leg, 610 
of arm, 616 
of muscles of hip, 614 
of posterior muscles of 

leg, 611 
of thigh muscles, 612 
of paralytic scoliosis, 616 
Popliteal region, bursse and cysts in, 

440 
Postural kyphosis, 225 
Posture in treatment of knock-knee, 

583 
Potbelly in rhachitis, 500 
Pott's disease, 17. See Tuberculous 
disease of spine, 
lumbar, in infancy, peculiarities 
of, 50 
paraplegia, 115 
Prepatellar bursitis, 439 
Pretibial bursa, superficial, enlarge- 
ment of, 440 
bursitis, 439 

symptoms of, 439 
treatment of, 440 
Progressive muscular atrophy, 633 
myelopathic form of, 633 
myopathic form of, 634 
Pseudohypertrophic muscular para- 
lysis, 634, 635 
Pseudoparalysis in rhachitis, 502 
Psoas contraction in tuberculous dis- 
ease of spine in lower region, 40 
Psychical torticollis, 664 
Puerperal arthritis, 272 



Quiet effusion at knee, 438 



Recurrent dislocation of shoulder, 
487 
treatment of, 487 
synovitis of knee, 435 
Relaxation of pelvic joints, 142 
Retardation of growth in acute ante- 
rior poliomyelitis, 608, 609 
Retention brace in treatment of in- 
fantile club-foot, 777 
Retrocalcaneobursitis, 730. SeeAchil- 
' lobursitis. 
Rhachitic attitude, 131, 502 

distortions of lower limbs, general, 

597 
rosary, 500 
spine, 130 

natural cure of, 131 



Rhachitic spine, treatment of, 131 

torticollis, 663 
Rhachitis, 498 

age of onset of, 498 

attitude in, 502 

caput quadratum in, 500 

craniotabes in, 500 

cubitus valgus in, 501 
varus in, 501 

deformities in, 500 
prevention of, 504 

double joints in, 500 

etiology of, 498 

foetal, 505 

Harrison's groove in, 500 

kyphosis in, 500 

pathology of, 499 

pigeon breast in, 500 

potbelly in, 500 

prognosis of, 502 

pseudoparalysis in, 502 

rhachitic rosary in, 500 

scoliosis in, 500 

symptoms of, 499 

treatment of, 503 
Rheumatism, 289 

of ankle-joint, 465 

gonorrhceal, 270. See Gonorrhceal 
arthritis 

of spine, 133. See Spondylitis de- 
formans. 
Rheumatoid arthritis, 284 
in childhood, 287 
etiology of, 287 
treatment of, 287 
Ribs, absence of, 231 

cervical, 231 
Rice bodies in tuberculous joint dis- 
ease, 256 
Rickets, 489. See Rhachitis. 

late, 504 

scurvy, 506 
Rigid weak foot, 706 

treatment of, 706 
Rotary lateral curvature of spine, 

149 
Rotation in lateral curvature of spine, 

151 
Round back, 223 
hollow, 223, 224 

shoulders, 225 
Rudimentary patella, 443, 444 



Sacroiliac articulation, injury of, 148 
disease, 146 

diagnosis of, 146 
prognosis in, 146 
symptoms of, 146 
treatment of, 147 
Sarcoma of femur, 403 
of spine 126 



860 



INDEX 



Scapula, congenital elevation of, 229 
etiology of, 230 
treatment of, 231 
Scapular crepitus, 236 
Scapulohumeral periarthritis, 478 
Sciatic scoliosis, 145 
Sciatica, deformity secondary to, 145 
Scoliosis, 149. See Lateral curvature 
of spine, 
hysterical, 638 
in rhachitis, 500 
Scorbutus, 290 
infantile, 506 

pathology of, 507 
symptoms of, 507 
treatment of, 507 
Scurvy, 290, 506 

rickets, 506 
Secondary deformities in neglected 
talipes, 789 
hypertrophic osteoarthropathy, 512 
Septic infection in tuberculous disease 

of bones and joints, 257 
Shaffer extension shoe in treatment of 

acquired talipes equinus, 818 
Shoes, 747 

in treatment of weak foot, 698 
Shoulder, congenital dislocation of, 
482 
dislocation of, congenital, reduction 
of deformity in, 484 
recurrent, 487 
treatment of, 487 
operative, 488 
Shoulder-joint, bursitis at, chronic, 
479 
tuberculous disease of, 466 
age at incipiency of, 467 

statistics of, 467 
pathology of, 466 
prognosis in, 469 
symptoms of, 467 
treatment of, 469 
operative, 469 
periarthritis of, 478 
symptoms of, 478 
treatment of, 479 
Signs, local, of tuberculous disease^f 

hip- joint, 325 
Sinuses in tuberculous disease of hip, 

treatment of, 382 
Skin, hypersesthesia of, in neurotic 

spine, 143 
Slipping patella, 444 
etiology of, 445 
symptoms of, 445 
treatment of, 446 
operative, 446 
Snapping finger, 495 
hip, 549 
knee, 447 

treatment of, 448 
Socks, 751 
Spasmodic torticollis, 659 



Spastic paralysis, 623 
spinal paralysis, 633 
Spina bifida and talipes, 812 

ventosa, 476 
Spinal cord, length of, 35 
ligaments, rupture of, 129 
paralysis, spastic, 633 
Spine, actinomycosis of, 128 

anteroposterior deformities of, 224 
kyphosis, 224 
lordosis, 228 

treatment of, 229 
arthritis of, infectious, 133 
suboccipital region of, 133 
treatment of, 133 
carcinoma of, 126 
changes in contour of, in Pott's 

disease, 28 
deformity of, tabetic, 140 
divisions of, 32 
fracture of, 129 

" gonorrhoeal rheumatism of," 133 
hysterical, 144 
symptoms of, 145 
treatment of, 145 
infectious arthritis, 133 

disease of coverings or articula- 
tions of, 132 
injury of, 128 
landmarks in diagnosis of disease 

of, 34 
lateral curvature of, 149 

changes in anteroposterior con- 
tour in, 155 
compensatory deformity in, 165 
congenital, 167 
deviation in, 151 
diagnosis of, 174 
mobility in, 175 
posture in, 174 
due to occupation, 167 
etiology of, 161 
hereditary influence in, 169 
high hip in, 156 

shoulder in, 156 
incidental, 166 

occupation as inducing de- 
formity, 170 
statistics of, 170 
pathology of, 157 
prevention of deformity in, 179 
records of, 175 
relative frequency of, 161 
statistics of, 161 
as to age, 162 
as to sex, 162 
rhachitic, 168 

statistics of, 168, 169 
rotation in, 151 

secondary to deformity else- 
where, 165 
to disease within thoracic 

walls, 165 
to paralysis, 165 



INDEX 



861 



Spine, lateral curvature of, symptoms 
of, 173 
treatment of, 179 

braces in, use of, 216 
duration of, 222 
exercises in, 184-200 
general, 185-200 
muscle building, 207 
self-correcting, 201 
Teschner's, 185 
forcible correction of de- 
formity in, 218 
combined with fixa- 
tion, 219 
general, 21 
high shoe in, 221 
posture in, 184 

and support during recum- 
bency in, 221 
removal of superincumbent 
weight in, 214 
by self-suspension, 214 
Volkmann seat in, 212 
varieties of deformity in, 172 
statistics of, 172 
ligaments of, rupture of, 129 
malignant disease of, 126 

diagnosis of, 127 
neurotic, 143 

hypersesthesia of skin in, 143 
symptoms of, 143 
treatment of, 144 
non-tuberculous affections of, 126 
normal, contour and flexibility of, 30 

variations in, 32 
osteoarthritis of, 133. See Spondy- 
litis deformans, 
osteomyelitis of, acute, 127 
symptoms of, 127 
treatment of, 128 
rhachitic, 130 
diagnosis of, from Pott's disease, 

50 
natural cure of, 131 
treatment of, 131 
rheumatism of, 133. See Spondy- 
litis deformans, 
rheumatoid arthritis of, 134 
sarcoma of, 126 
syphilis of, 126 

diagnosis of, 126 
tabetic deformity of, 140 
tuberculous disease of, 17 
complications of, 108 
abscess, 108 

course and peculiarities of, 

110 
in different regions, 110 
statistics of, 108 
treatment of, 112 
aspiration in, 114 
injections in, 114 
correction of deformity in, 
Calot's operation in, 123 



Spine, tuberculous disease of, correc- 
tion of, deformity in, 
forcible, 123 
Goldthwait's apparatus in, 

91 
Metzger-Goldthwait's ap- 
paratus in, 93 
diagnosis of, 61-65 

Roentgen rays in, 65 
history in, 36 
later effects of deformity in, 

125 
in lower region, 39, 60 
attitude in, 39 

diagnosis of, from bilateral 
congenital dislocation of 
hip, 48 
differential, 46 
from hip disease in in- 
fancy, 48 
from lumbago, 46 
from muscular dystro- 
phies, 48 
from sacroiliac disease, 47 
from sciatica, 46 
from secondary hip dis- 
ease, 49 
from spondylolisthesis, 47 
from strain in back, 46 
gait in, 39 

location of pain in, 41 
lordosis in, 39, 40 
pelvic abscess in, 45 

diagnosis of, differen- 
tial, 49 
psoas contraction in, 40 
paralysis in, 115 
duration of, 117 
frequency of, 116 
liability to, in different 

regions, 116 
local, 123 
prognosis of, 120 
symptoms of, 118 
time of onset, 117 
treatment of, 120 
laminectomy in, 122 
operative, 121 
physical signs of, 37 
rational signs of, 35 
record of the case in, 66 
recurrence of, 125 
secondary deformities of, 125 
in thoracic region, 52 
abscess in, 55 
attitudes in, 52 
deviation of spine in, 54 
diagnosis of, 55 

differential, 56 
muscular spasm in, 54 
pain in, 53 
pigeon chest in, 52 
respiration in, 54 
treatment of, 67 



862 



INDEX 



Spine, tuberculous disease of, treat- 
ment of, duration of, 123 
indications for, by recum- 
bency, 100 
special, of different re- 
gions, 101 
lower dorsal region, 
105 
region, 102 
middle cervical re- 
gion, 106 
dorsal region, 106 
occipitoaxoid re- 
gion, 107 
upper dorsal re- 
gion, 106 
mechanical ambulatory sup- 
ports in, 76 
back brace, 76 
comparison of, 96 
corset, Phelps, 98 
plaster, 95 
Weigel's, 98 
corsets, 95, 97 
plaster corset, 95 
jacket, 82 

application of, in 
recumbency,91 
modifications of, 
97 
Taylor brace in, 76, 
79 
head support, 82 
Bradford frame in, 69 

modifications of, 69, 70 
general principles of, 67 
horizontal fixations in, 68 
Lorenz apparatus in, 68 
Phelps' bed in, 68 
principles of, in their prac- 
tical application, 98 
wire cuirasse in, 69 
in upper region, 58 
abscess in, 59 
attitude in, 58 
symptoms of, 58 
typhoid, 132 

diagnosis of, 132 
treatment of, 132 
variations in contour of, 223 
Splint, Billroth, in treatment of tuber- 
culous disease of knee-joint, 419 
in treatment of infantile club-foot, 
773 
Spondylitis deformans, 133 
cases of, 137 
pathology of, 133 
symptoms of, 136 
synonyms of, 133 
treatment of, 138 
varieties of, 134 
superficialis, 18 
traumatic, 129 
treatment of, 129 



Spondylolisthesis, 140 

Spondylose rhizomelique, 134. See 

Spondylitis deformans. 
Spontaneous dislocation of hip-joint, 
400 
subluxation of wrist, 490 
Sprain of ankle, 459 
chronic, 462 

treatment of, 462 
symptoms of, 459 
treatment of, 459 
strapping in, 460 
of wrist, 480 
chronic, 480 
Sprengel's deformity, 229 
etiology of, 230 
treatment of, 231 
Sternomastoid muscle, hsematoma of, 

646 
Stiffness as symptom of tuberculous 

disease of hip- joint, 305 
Strains of knee in childhood, 434 

of tendo Achillis, 733 
Strapping in treatment of sprain of 

ankle, 460 
Subacute arthritis of hip-joint, 400 
Subastragaloid disease, 453 
Subluxation of clavicle, 236 
treatment of, 236 
of hip, congenital, 549 
of wrist, 490 
etiology of, 491 
spontaneous, 490 
treatment of, 491 
Support in treatment of weak foot, 

700 
Supracotyloid dislocation at hip- 
joint, 524 
Swelling about ankles, 465 
Synovial tuberculosis, arborescent,255 
of knee-joint, 427 
treatment of, 427 
Synovitis of knee, acute, 434 
chronic, 435 
incidental, 438 
painless, 438 
recurrent, 435 
Syphilis of spine, 126 
diagnosis of, 126 
Syphilitic diseases of joints, 266 
osteochondritis, 266 
osteoperiostitis, 266 
pain and swelling of joints, 267 



Tabetic deformity of spine, 140 
Talipes, 752 

acquired, 638, 755, 813 

deformity in, development of, 

814 
diagnosis of, differential, from 
congenital talipes, 815 



INDEX 



863 



Talipes, acquired, etiology of, 813 
arcuatus, 716. See Contracted 

foot, 
calcaneovalgus, 754 
acquired, 830 

treatment of, 830 
congenital, 808 
calcaneovarus, 754 

congenital, 808 
calcaneus, 753 
acquired, 822 

deformity in, development of, 

823 
symptoms of, 823 
treatment of, 824 
Judson brace in, 824 
operative, 825 

Whitman's operation in, 

828 
Willett's operation in, 826 
congenital, 807 
cavus, 716. See Contracted foot, 
congenital, 638, 755 
anatomy of, 762 
etiology of, 756 
other varieties of, 806 
equinocavus, congenital, 808 
equinovalgus, 754 

associated with congenital ab- 
sence of fibula, 809 
etiology of, 810 
statistics of, 809 
treatment of, 810 
congenital, 808 
equinovarus, 754 
anatomy of, 762 

associated with congenital ab- 
sence of tibia, 811 
prognosis of, 811 
statistics of, 811 
infantile, treatment of, 767 
symptoms of, 766 
treatment of, 767 
equinus, 753 
acquired, 815 
etiology of, 816 
symptoms of, 817 
treatment 818 

arthrodesis in, 821 
immediate correction of de- 
formity in, 818 
Thomas' wrench in, 

819 
tonic effect of, 820 
manipulation in, 818 
Shaffer extension shoe in, 
818 
congenital, 807 
infantile, treatment of, 767 
first stage of, 768 
Judson's brace in, 773 
manual correction in, 779 
mechanical, 769 
plaster bandage, in 769 



Talipes, infantile, treatment of, pre- 
liminary manipulation in, 
769 
principles of, 768 
rectification of deformity in, 

768 
retention brace in, 777 
second stage of, 776 
splints and braces in, 773 
support in second stage of, 

776 
Taylor brace in, 777 
tenotomy in, 775 
neglected, secondary deformities in, 
789 
treatment of, 780 
age influencing, 781 
division of tendo Achillis in, 

791 
forcible manual correction in, 

782 
importance of functional use 

in, 787 
malleotomy in, 789 
by method of Julius Wolff, 

793 
open incision combined with 
forcible rectification of de- 
formity in, 797 
method of, 792 
operations on astragalectomy, 
800 
bones in, 800 

cuneiform osteotomy in, 800 
secondary osteotomy, 802 
by osteoclasts, 794, 796 
Phelps' operation in, 797 
rapid correction of deformity 

in, 781 
simple mechanical rectification 
of deformity in walking child- 
ren, 802 
subcutaneous tenotomy in, 790 
Thomas' method in, 795 
by wrenches, 794 
paralytic, arthrodesis in, 841 
tendon splicing in, 841 

transplantation in combination 
with other procedures, 840 
for relief of, 833 
the operation, 837 

modifications of, 838 
selection of muscles for, 

834 
time for operation of, 834 
plantaris, 716. See Contracted foot, 
spina bifida and, 812 
statistics of, 760 

relative frequency of different 
forms of, 742 
valgocavus, congenital, 808 
valgus, 753 

congenital, 807 
varieties of, 753 



864 



INDEX 



Talipes varus, 753 

associated with congenital 

absence of tibia, 811 
congenital, 806 
Tarsus, tuberculous disease of, 458 

distribution of, to individual 

bones, 458 
statistics of, 458 
treatment of, 459 
Taylor brace in treatment of infantile 

club-foot, 777 
Tendo Achillis, division of, in treat- 
ment of neglected talipes, 791 
strain of, 733 
Tendon transplantation in treatment 

of paralytic deformities, 618 
Tenosynovitis at ankle-joint, 463 
treatment of, 463 
tuberculous, 464 
at wrist-joint, acute, 480 
Tenotomy, subcutaneous, in treat- 
ment of neglected talipes, 
790 
of torticollis, 654 
in treatment of infantile club-foot, 
775 
Thomas brace in treatment of knock- 
knee, 585 
knee brace in treatment of tuber- 
culous disease of knee-joint, 420 
method in treatment of neglected 

talipes, 795 
treatment of rigid weak foot, 713 
wrench in treatment of acquired 
tahpes equinus, 819 
Tibia, anterior curvature of, 595 

displacement of, 442. >SeeGenu 
recurvatum, congenital. 
Tibial tubercle, injury of, 440 
Toe, hammer, 744 

-joint, painful great, 737 
overlapping, 745 
painful, great, 735 
pigeon, 739 
Torticollis, 642 
acquired, 642, 648 

table of exciting causes of, 650 
varieties of, 648 
acute, 648 

etiology of, 648 
spastic, 649 
symptoms of, 650 
treatment of, 657 
chronic, treatment of, 654 
by manipulation, 654 
congenital, 642, 643 
etiology of, 645 
pathology of, 647 
treatment of, 654 

by manipulation, 654 
by open method, 655 
overcorrection of deformity in, 

655 
by subcutaneous tenotomy, 654 



Torticollis, diagnosis of, 651 
from arthritis, 653 
from Pott's disease, 651 
following diphtheritic paralysis, 663 
irregular forms of, 648, 663 
ocular, 663 
paralytic, 663 
psychical, 664 
rhachitic, 663 
spasmodic, 648 
etiology of, 659 
pathology of, 659 
prognosis in, 659 
treatment of, 659 

description of operation in, 

660 
operative, 659 
treatment of, 653 

by manipulation, 654 
Traction in treatment of tuberculous 

disease of knee-joint, 418 
Transplantation of Sartorius muscle, 

619 
Traumatic coxa vara, 562 

separation of epiphysis of head of 

femur, 564 
spondylitis, 129 
Traumatisms at hip- joint, 398 
Treatment of abscess in tuberculous 
disease of hip, 380 
of knee-joint, 426 
accessory, of tuberculous disease of 

knee-joint, 424 
of achillobursitis, 731 

operative, 732 
of acquired genu recurvatum, 442 
tahpes calcaneovalgus, 830 
calcaneovarus, 830 
calcaneus, 824 
equinovalgus, 832 
equino varus, 831 
equinus, 818 
of acute anterior poliomyelitis, 610 
mechanical principles of, 610 
operative, 616 
epiphysitis at hip-joint, 399 
infectious arthritis of hip-joint, 

399 
osteomyelitis of spine, 128 
torticollis, 657 
of anchylosis, 293 

forcible correction in, 295 
operative exploration in, 296 
passive motion in, 294 
of anterior bow-leg, 597 

metatarsalgia, 727 
of arthritis complicating infectious 
diseases, 273 
deformans, 404 

of suboccipital region of spine, 
133 
Bier's, of tuberculous disease of 

knee-joint, 425 
of bilateral hip disease, 376 



INDEX 



865 



Treatment of bow-leg, 592 
by braces, 592 
expectant, 592 
operative, 594 
of bursitis, 403 
of calcaneobursitis, 734 
of cerebral paralysis of childhood, 

629 
of Charcot's disease, 292 
of chondrodystrophia, 506 
of chronic sprain of ankle, 462 
of club-hand. 493 

of congenital contraction of fingers, 
494 
at knee, 448 
dislocation at hip-joint, 526 
elevation of scapula, 231 
genu recurvaturn, 443 
torticollis, 654 
of contracted foot, 719 

operative, 720 
of coxa vara, 558 

operative, 560 
of displacement of peronei tendons, 

746 
of Dupuytren's contraction, 497 
during convalescence from tuber- 
culous disease of knee-joint, 425 
of elongation of ligamentum patel- 
la}, 447 
of extra-articular disease of knee- 
joint, 426 
of flat chest, 232 
of gonorrhceal arthritis, 272 
of hallux rigidus, 736 
valgus, 741 

operative, 742 
varus, 739 
of haemophilia, 290 
of hammer-toe, 745 
of hemiplegia in cerebral paralysis 

in childhood, 629 
of hysterical joint affections, 638 

spine, 145 
of infantile talipes, 767 
of internal derangement of knee- 

;oint, 436 
of jerking finger, 496 
of knock-knee, 583 
by braces, 585 
expectant, 583 
operative, 587 
of kyphosis,226 

of lateral curvature of spine, 179 
braces in, use of, 216 
duration of, 222 
exercises in, 184-200 
muscle building, 207 
self-correcting, 201 
Teschner's, 185 
forcible correction of de- 
formity in, 218 
combined with fixa- 
tion, 219 



Treatment of lateral curvature of 
spine, high shoe in, 221 
posture in, 184 

and support during re- 
cumbency in, 221 
removal by self -suspension, 

214 
of superincumbent weight in, 

214 
Volkmann seat in, 221 
of lordosis, 229 

mechanical, of tuberculous disease 
of hip-joint, 333 
of knee-joint, 420 
of neurotic spine, 144 
of obstetrical paralysis of arm, 483 
of osteoarthritis, 284 

of hip-joint, 404 
of osteomalacia, 509 
of pain in lower portion of back, 143 
of painful heel, 734 
of paralysis in tuberculous disease 
of spine, 120 
duration of, 123 
laminectomy in, 122 
operative, 121 
of paralytic scoliosis, 616 
of paraplegia in cerebral paralysis 

of childhood, 631 
of periarthritis of shoulder, 479 
of pigeon chest, 234 
of plantar neuralgia, 734 
of prepatellar bursitis, 439 
of pretibial bursitis, 440 
of recurrent dislocation of shoulder 
487 
operative, 488 
of rhachitic spine, 131 
of rhachitis, 503 
of rheumatoid arthritis, 287 
of rudimentary patella, 444 
of sacroiliac disease, 147 
of scorbutus, 507 
of sinuses in tuberculous disease of 

hip, 382 
of slipping patella, 446 

operative, 446 
of snapping finger, 496 

knee, 448 
of spasmodic torticollis, 659 

operative, 660 
of spondylitis deformans, 138 
of sprain of ankle, 459 
of Sprengel's deformity, 231 
of subluxation of clavicle, 236 

of wrist, 491 
of suppurative arthritis in infancv, 

275 
of synovial tuberculosis of knee- 
joint, 427 
of syphilitic diseases of joints, 269 
of talipes equinovalgus associated 
with congenital absence of fibula, 
810 



55 



866 



INDEX 



Treatment of tenosynovitis at ankle- 
joint, 463 
of torticollis, 653 
of traumatic coxa vara, 563 

spondylitis, 129 
of traumatisms at hip- joint, 398 
of trigger finger, 496 
of tuberculous disease of ankle-joint, 
455 
operative, 456 
of bones and joints, 260 

active congestion in, 262 
by drugs, 261 
local application in, 261 
passive congestion in, 262 
cc-rays in, 262 
of elbow-joint, 472 

excision of elbow in, 473 
operative, 473 

reduction of deformity in, 
473 
of hip-joint, 332 
of knee-joint, 416 
of shoulder-joint, 469 

operative, 469 
of spine, 67 

ambulatory supports in, 76 
application of, in re- 
cumbency, 91, 94 
comparison of, 96 
back brace in, 76 
corsets in, 95, 97 
plaster, 95 
Phelps', 98 
Weigel's, 98 
indications for, by recum- 
bency, 100 
special,of different regions, 
101 
mechanical, ambulatory sup- 
ports in, Taylor 
brace in, 76, 79 
head support, 82 
Thomas collar, 98 
Bradford frame in, 69 

modifications of, 69, 70 
general principles of, 67 
horizontal fixation in, 68 
Lorenz's apparatus in, 68 
Phelps' bed in, 68 
principles of, in their prac- 
tical application, 9S 
wire cuirasse in, 69 
plaster corset, 95 
jacket, 82 

modifications of, 97 
of tarsus, 459 
of wrist-joint, 475 
of typhoid spine, 130 
of weak foot, 697 
of webbed fingers, 495 
Trigger finger, 495 
etiology of, 495 
treatment of, 496 



synovial, arborescent, 



Tuberculosi: 
255 

of knee-joint, 427 
treatment of, 427 
Tuberculous arthritis, acute, 276 
disease of ankle-joint, 449 
age at incipiency of, 450 

statistics of, 450, 451 
astragalonavicular disease in, 

453 
deformity in, 452 
diagnosis of, 453 
etiology of, 450 
pathology of, 449 
physical examination in, 450 
prognosis in, 457 

statistics of, 457 
situation of, 450 

statistics of, 450 
subastragaloid disease in, 454 
symptoms of, 451 
treatment of, 455 
operative, 456 

reduction of deformity in, 
455 
of bones and joints, 246 

arborescent synovial, 255 
caries sicca, 256 
diagnosis of, 259 
distribution of disease in, 249 
statistics of, 249 
age, 250 
sex, 250 

side affected, 250 
etiology of, 246 
latent tuberculosis as cause 

of, 246 
lipoma arborescens, 255 
local predisposition to, 248 
mode of infection in, 244, 246 
other forms of, 254 
pathology of, 251 
perforation of joint in, 251 
predisposition to, 246 
prognosis in, 257 
repair in, 257 
rice bodies, 256 
septic infection in, 257 
treatment of, 260 

active congestion in, 264 
carbolic acid locallv in, 

262 
by drugs, 261 
iodoform locally in, 261 
local applications in, 261 
passive congestion in, 262 
.r-rays in, 262 
of elbow-joint, 470 

age at incipiency of, 470 

statistics of, 470 

pathology of, 470 

symptoms of, 471 

treatment of, 472 

excision in, 473 



INDEX 



867 



Tuberculous disease of elbow-joint, 
treatment of, excision in, 
statistics of, 473 
operative, 473 

reduction of deformity in, 
473 
of hip-joint, 298 
abscess in, 378 

significance of, 379 
treatment of, 380 

exploratory operations,382 
actual lengthening of limb in, 
318 
shortening of limb in, 316 
in adult, 377 
age at incipiencj^ 302 
statistics of, 302 
amputation in, 388 
bilateral, 375 

treatment of, 376 
combined with disease of other 

parts, 376 
correction of deformity by 

femoral osteotomy, 390 
deformities of other parts 

caused by, 396 
details of 1000 cases of, 330 
diagnosis of, from anterior 
poliomyelitis, 326 
from congenital dislocation 

of hip, 329 
from coxa vara, 328 

traumatic, 328 
differential, 326 
from disease of bursse about 

joint, 328 
from epiphysitis, 327 
from extra-articular disease, 

327 
from fracture of neck of 

femur in childhood, 328 
from gonorrhceal arthritis, 

327 
from growing pains, 326 
from hysterical joint, 329 
from infectious arthritis, 327 
from local injiny, 326 

irritation, 326 
from osteoarthritis of hip, 

327 
from pelvic disease, 328 
from Pott's disease, 327 
from rheumatism, 326 
from sacroiliac disease, 328 
from scurvy, 326 
from synovitis, 326 
x-rays as means of, 329 
distortion of limb in, 307 
apparent lengthening, 307 
shortening, 310 
etiology of, 302 

examination in, method of, 
320 
physical, 320 



Tuberculous disease of hip-joint, exci- 
sion of hip in, 384 
Koenig's method of, 384 
history of case of, 320 
in infancy, 377 
Koenig's statistics of, 310 
local signs of, 325 
measurements in, 321 
method of estimating degree of 
distortion of limb 
in, 322 
Kingsley's table, 325 
Lovett's table, 323 
of examination in, 320 
of recording case of, 329 
formuke used, 330 
mortality in, 391 

causes of death, 392 
natural cure in, 310 
pathology of, 298 
prognosis of, 391 

as to function, 394 
reduction of deformity in re- 
sistant cases, 388 ► • 
relative frequency of, 302 
retardation of growth in, 317 
sex affected in, 302 
statistics of, 302 
side affected in, 303 

statistics of, 303 
sinuses in, 382 

treatment of, 382 
symptoms of, 303 
atrophy as, 313 
change in contour of hip as, 

313 
distortion of limbjis, 307 
general, 319 
debility, 319 
fever, 320 
limp as, 303, 304 
night cry as, 304 
pain as, 303, 304 
stiffness as, 305 
treatment of, 332 

application of plaster spica 

bandage in, 350 
during stage of recovery, 371 
immediate reduction of de- 
formity in, 353 
Lorenz's spica bandage in, 

351 
mechanical, 333 

application of traction 

splint in, 338 
high shoe in, 338 
perineal bands in, 338 
splinting in, 334 
stilting in, 334, 
Taylor's method of trac- 
tion in, 336 
traction in, 334 
hip splint for, 334 
plasters in, 336 



INDEX 



Tuberculous disease of hip-joint, 
treatment of, mechanical 
traction in, straps for, 336 
by plaster bandage, 349 
practical combination of 
traction, splinting and 
stilting in, 361 
reduction of deformity in, 
immediate, 353 
lateral traction in, 358 
by Thomas' method, 

346 
by traction brace in, 340 
by weights and pullevs, 
350 
Marsh's appliance 
for, 356 
relative efficiency of traction 
hip splint in, 341 
and splinting in, 359 
removal of direct pressure in, 

360 
stilting, 360 
Thomas', 343 
brace in, 344 

modifications of, 348 
of knee-joint, 406 
abscess in, 426 

Koenig's statistics of, 426 
treatment of, 426 
actual lengthening of limb in, 
414 
statistics of, 414 
shortening in, 414 
statistics of, 414 
deformity in, 432 
diagnosis of, 415 

from acute epiphysitis, 415 
from Charcot's disease, 416 
from hff>marthrosis, 415 
from hysterical joint, 416 
from infectious arthritis,415 
from injury of knee, 415 
from osteoarthritis, 416 
from rheumatism, 416 
from rheumatoid arthritis, 

416 
from sarcoma, 416 
from synovitis, 415 
distortions in, primary, 411 

secondarv, 412 
etiology of," 409 
extra-articular, 426 

operative intervention in, 

426 
treatment of, 426 
functional results of treatment 

of, 432 
mortality in, 431 
causes of, 431 
influence of age on, 432 

statistics of, Koenig's, 
432 
pathology of, 406 



Tuberculous disease of knee-joint, 
primary distortions in, 411 
prognosis in, 431 
statistics of, 431 
Gibney's, 431 
secondary distortions in, 412 
statistics of, 409 

age at incipiency, 409 

on course and outcome of, 

431 
of results of treatment of, 
431 
symptoms of, 409 
synonyms of, 406 
svnovial tuberculosis, 427 

treatment of, 427 
treatment of, 416 
accessory, 424 

Bier's treatment of, 425 
cautery as, 424 
ichthyol ointment as, 424 
iodoform emulsion injec- 
tion as, 424 
x-rays as, 424 
amputation in, 430 
arthrectomv in, 427 
results of, 428 
statistics of, 428 
Billroth splint in, 419 
excision in, 428 
results of, 429 

statistics of, 429, 430 
forcible correction by re- 
verse leverage in, 418 
functional results of, 432 
mechanical, 420 

caliper brace in, 423 
Thomas knee brace in, 420 
operations for relief of final 

deformity in, 430 
plaster bandage in, 417 
reduction of deformitv in, 

417 
statistics of results of, 431 
traction in, 418 
of shoulder-joint, 466 
age at incipiencv of, 467 

statistics of. 467 
pathology of, 466 
prognosis of, 469 
symptoms of, 467 
treatment of, 469 
operative, 469 
of spine, 17 
abscess in, 29 
age at time of onset of, 22 
attitude in, change in, 28 
compensatory deformity in, 28 
complications of, 108 
abscess, 108 

course and peculiarities 

of, 110 
in different regions, 110 
statistics of, 108 



INDEX 



869 



Tubeiculous disease of spine, compli- 
cations of, abscess 
in, treatment of, 112 
aspiration in, 114 
injections in, 114 
contour of spine in, changes in, 

28 
correction of deformity in, 123 
Calot's operation, 123 
of deformity in, forcible, 123 
Goldthwait apparatus in, 91 
Metzger-Goldthwait appa- 
ratus in, 93 
deformity in, 17 
compensator}-, 28 
muscular, 28 
diagnosis of, in general, 65 

Roentgen rays in, 65 
etiology of, 22 
history in, 36 

impairment of function in, 28 
later effects of deformity in, 

125 
in lower cervical region, £0 
diagnosis of, 61 
from abscess, 64 
from acute articular 

rheumatism, 64 
from cervical opis- 
thotonos, 63 
from injury, 63 
from rheumatoid ar- 
thritis, 64 
from torticollis, 61, 62 
region, 39 

attitude in, 39 

diagnosis of, from bi- 
lateral congenital 
dislocation of hip, 
48 
from hip disease in 

infancy, 48 
from lumbago, 46 
from muscular dystro- 
phies, 48 
from sacroiliac dis- 
ease, 47 
from sciatica, 46 
from secondary hip 

disease, 49 
from spondylolisthe- 
sis, 47 
from strain of back, 
46 
gait in, 39 

in infancy, differential 
diagnosis of, 50 
lateral inclination of bodv 

in, 41 
location of pain in, 41 
lordosis in, 39, 40 
pelvic abscess in, 45 

diagnosis of, differen- 
tial, 49 



Tuberculous disease of spine in lower 
region, pelvic ab- 
scess in, diagno- 
sis of, from ap- 
pendicitis, 49 
from hernia, 50 
from perinephritic 
abscess, 49 
psoas contraction in, 40 
mortality in, 25 
muscular deformity in, 28 
"night cry" in, 28 
pain in, 27 
paralysis in, 29, 115 
duration of, 117 
frequency of, 116 
liability to, in different 

regions, 116 
local, 123 
prognosis of, 120 
symptoms of, 118 
time of onset of, 117 
treatment of, 120 
laminectomy in,122 
operative, 121 
pathology of, 18 
physical signs of, 37 
prognosis in, 25 
rational signs of, 35 
record of the case in, 66 
recurrence of, 125 
relative frequency of, 22 

of dorsal and lumbar in- 
volvement in, 23 
secondary deformities of, 125 
sex in, 23 

situation of disease in, 23 
stiffness in, 28 
symptoms of, 26 
complicating, 29 
general, 30 
secondary, 29 
in thoracic region, 52 
abscess in, 55 
attitudes in, 52 
deviation of spine in, 54 
diagnosis of, 55 

differential, 56 
muscular spasm in, 54 
pain in, 53 
pigeon chest in, 52 
respiration in, 54 
treatment of, 67 
duration of, 123 
indications for, special, of 
different regions, 100 
middle cervical region, 

106 
occipitoaxoid region, 107 
upper dorsal region, 106 
by recumbency, 100 
special, of different regions, 
101 
lower dorsal region, 105 



870 



INDEX 



Tuberculous disease of spine, treat- 
ment of, indications 
for, special, lower re- 
gion, 102 
middle dorsal region, 
106 
mechanical ambulatory sup- 
ports in, 76 
back brace, 76 
comparison of, 96 
corsets, 95, 97 
corset, plaster, 95 
Phelps', 98 
Weigel's, 98 
plaster corset, 95 
plaster jacket, 82 

application to pa- 
tients who have 
been treated on 
stretcher frames, 
94 
modifications of, 97 
in recumbency, 91 
Taylor brace, 76, 79 

head support, 82 
Thomas collar, 98 
Bradford frame in, 69 

modifications of, 69, 
70 
general principles of, 67 
horizontal fixation in, 

68 
Lorenz's apparatus in, 68 
Phelps' bed in, 68 
principles of, in their 
practical application, 
98 
wire cuirasse in, 69 
in upper region, 58 
abscess in, 59 
attitude in, 58 
symptoms of, 58 
weakness in, 28 
of tarsus, 458 

distribution of, to individual 
bones, 458 

statistics of, 458 
treatment of, 459 
of wrist-joint, 474 

age at incipiency of, 475 

statistics of, 475 
prognosis in, 475 
statistics of, 474 
symptoms of, 475 
treatment of, 475 
tenosynovitis at ankle-joint, 464 
Typhoid spine, 132 
treatment of, 132 



U 



Unilateral dislocation at hip-joint, 
251 
knock-knee, 580 



Vertebrae, absence of, 231 
Vertebral column, stiffness of, 133 
Volkmann seat in treatment of lateral 
curvature of spine, 221 



W 

Weak ankles in childhood, 694 
foot, 679 

in childhood, 694 

deformity of legs with, 695 
general weakness in, 696 
irregular forms of, 695 
outgrown joints in, 695 
out-toeing and in-toeing in, 694 
symptoms of, 694 
weak ankles in, 694 
deformity in, 679 
diagnosis of, 687 
etiology of, 683 
extreme types of, 692 
persistent abduction, 692 
pes planus, 692 
limitation of motion and muscu- 
lar spasm in, 692 
pathology of, 683 
rigid, 706 

functional use in overcorrected 

attitude in, 708 
treatment of, 706 
adjuncts in, 713 
forcible overcorrection in, 

707 
operative, 714 
plaster strapping in, 713 
systematic manipulations in, 

709 
Thomas', 713 
varieties of, 712 
symptoms of, 685 
treatment of, 697 
attitudes in, 699 
brace in, 703 

construction of, 701 
positive action of, 704 
exercises in, 699 
raising inner border of shoe in, 

699 
the shoe in, 698 
support in, 700 
varieties of, 691 
Weakness of anterior metatarsal arch, 

721 
Webbed finger, 495 
etiology of, 495 
treatment of, 495 
Whitman's operation for acquired 

talipes calcaneus, 828 
Willett's operation for acquired talipes 

calcaneus, 826 
Wolff's law of functional pathogenesis 
of deformity, 238 



JA'DEX 



871 



Wolff's treatment of knock-knee, 589 
Wrenches in treatment of neglected 

talipes, 794 
Wrist, deformities of, congenital, 491 
-joint, tenosynovitis at, acute, 4S0 
tuberculous disease of, 474 
age at incipiency of, 475 

statistics of, 475 
prognosis in, 475 
statistics of, 474 
symptoms of, 475 
treatment of, 475 
sprain of, 480 



Wrist, sprain of, chronic, 480 
subluxation of, 490 

etiology of, 491 

spontaneous, 490 

treatment of, 491 
Wrvneck, 642. See Torticollis. 



X-rays as accessory in treatment of 
tuberculous disease of knee-joint, 
424 



•inn xv «^vi 



